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 SFY25 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 SFY26.
 

Narrative Updated: 05/02/25

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

Targeted outreach to providers has been implemented to improve data percentages. This approach includes collaboration with Gainwell Provider Representatives to engage providers and educate best practice with prior authorization submissions and documentation requirements.