Clinical Services Team: Clinical Operations Unit

% of initial prior authorization requests closed out within 28 days

99.4%SFQ3 2022

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Partners
  • DVHA Chief Medical Officer (CMO)
  • DVHA Data Unit
  • DVHA Member and Provider Services Unit
  • Medicaid enrolled Providers and Vendors
  • DVHA Fiscal Agent
Story Behind the Curve

This performance measure is important because prior authorization determinations of medical necessity are expected to adhere to Medicaid Rules and Federal Guidelines specified completion timeframes.

Medical determinations are made using evidence-based clinical guidelines.  Reaching a goal of 100% is heavily dependent on prior authorization request volumes, receipt of all clinical documentation from requesting provider, adequate staffing, and accurate data analysis.

SFY22 Q2 is 100.0% and reflects reaching the established goal of 100% for two consistent quarters.  The trend line for this measure has remained consistently high since 2019. 

Narrative last updated:  02/15/22

Strategy

In 2020, the COU implemented the following strategies in an effort to improve performance on this measure:

  • New prior authorization changes listed on DVHA/COVID website
  • DVHA website address added to COU voicemail to provide additional resources to providers seeking PA information
  • Bi-weekly review of prior authorization data that reflects prior authorization requests in informational status
Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy