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.