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Clinical Services Team

Ret: % of pharmacy prior authorizations processed within 4 and 24 hours

Current Value

99.4%

Mar 2023

Definition

Line Bar

Notes on Methodology

Please note that in the chart above:

  • The dotted trendline represents the % of PA processed in 4 hours or less
  • The solid trendline represents the % of PA processed in 24 hours or less

Story Behind the Curve

This performance measure is important because it allows the Pharmacy Unit to ensure that both contractual and Federal requirements are met by our vendor Change Healthcare by monitoring pharmacy prior authorization (PA) processing turnaround time.

This performance measure shows the percentage of PAs turned around in 24-hour and 4-hour time periods. This time period is measured from the time a PA request is received in the Call Center until a PA determination is made by Call Center staff and a Notice of Decision is issued. This measure ensures contract obligations as well as CMS required timeframes for PA evaluations are being met.

The solid trendline tells us that the average # of PAs processed within 24-hours for July to December 2022 is consistently between 99-100% each month.  In January 2023 it dropped to 98.5%, due to an overall increase in prior authorization volume. The dotted trendline shows that PAs processed within 4 hours continues to reach95% or higher each month. This helps measure the vendor’s performance and supports DVHA’s pharmacy PA program when speaking with providers and other stakeholders.

Narrative last updated:  04/12/23

Partners

  • Change Healthcare-Provider Call Center Staff
  • DVHA’s Enrolled Prescribers and Pharmacies

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