Please note that in the chart above:

• The dotted trendline represents the % of PA finalized in 28 days or less
• The solid trendline represents the % of PA finalized in 14 days or less

This performance measure is important because prior authorization (PA) determinations of medical necessity are expected to adhere to specified completion timeframes outlined in Medicaid Rules and Federal Guidelines 42 CFR §438.210(d):  For standard authorization decisions, provide notice as expeditiously as the enrollee’s health condition requires and within State-established time-frames that may not exceed 14 calendar days following receipt of the request for service, with a possible extension of up to 14 additional calendar days, if the enrollee or the provider requests the extension; or the MCO justifies the need for additional information and how the extension is in the enrollee’s interest.

Data analysis in late SFY23 determined that standard authorization determination decisions were being delayed in an effort to acquire necessary clinical information from providers. Although a delay in completing a medical necessity determination may benefit members, it is expected to be the exception.  To improve PA efficiencies and adhere to expected completion timeframes, DVHA providers have been given guidance on DVHA PA submission requirements through multiple communications. 

The solid trendline in the graph above shows the determination decisions made within 14 days and the dotted trendline shows the determinations for which an exception was made, and the decisions were made within 28 days.  The efforts the Clinical Operations Unit are making to improve the timeliness of PA determination decisions are outlined in the Strategy section below; DVHA anticipates both rates will increase over SFY24.

Updated: 09/28/23

• DVHA Chief Medical Officer (CMO)
• DVHA Data Unit
• DVHA Member and Provider Services Unit
• DVHA enrolled Providers and Vendors
• DVHA Fiscal Agent

In SFY24, the COU is implementing the following strategies to improve performance on this measure:

• Internal education of DVHA Clinical Operations Unit staff to reduce the use of informational status.
• Development and distribution of Information Status Document to support provider education.
• Implement revised prior authorization request forms to clarify the specific information required to complete a clinical review and best support providers submitting the necessary documentation the first time.
• Utilization of OnBase to monitor PA requests that are in Information Status.
• Working with Gainwell Provider Reps in supporting the COU in provider education around the PA process.
• Creation of educational tools and presentation for providers on PA topics.