Clinical Services Team: Clinical Operations Unit

% of initial prior authorization requests that have a decision rendered within 3 days of receiving all necessary information

81.9%SFQ3 2022

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Notes on Methodology

The target for this measure (represented with the red dotted line above) is 100%.

The methodology for calculating this measure was revised during SFY 2021, resulting in more accurate data collection starting in SFY21 Q3, which has been set as our new baseline.

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

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

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

The Clinical Operations Unit has historically monitored this performance measure and in late SFY2020 determined there were flaws in data collection methodology and recognized other contributing factors that have continued to result in a rate below the established target.  SFY2022 Q3 shows an 82% rate reflecting a continued trend of % rates between 82% and 84% since the end of SFY2021.

Last updated: 04/28/22
Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy