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.

The trend line for this measure has remained consistently high since 2021.  Previous strategies implemented to support attaining the target included listing prior authorization changes on the DVHA website and adding the DVHA website address to the COU voicemail to provide additional resources to providers seeking PA information.  Currently, a little less than half of the prior authorization request volume received for review require additional clinical information to be submitted by the requesting provider to complete a determination for medical necessity.  As a result, the prior authorization review time is extended while the request remains in “informational status” awaiting the requested and necessary additional clinical supporting documentation to complete the requested review for services.

Narrative last updated:  01/10/23

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

In SFY23, the COU used the following strategies to improve performance on this measure:

• 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.
• Continued the bi-weekly review of prior authorization data that reflects prior authorization requests in informational status.
• Internal education of DVHA Clinical Operations Unit to support best practice of clinical review and systems utilization
• Development of Information Status document to support provider education