Current through November, 2024
(a) Selected drugs
designated by the medical assistance program through the processes set forth in
section 17-1737-71 pursuant to
42 U.S.C.
1396 r(8)(d)(5) require prior medical
authorization.
(b) Preferred drug
list:
(1) The department may maintain a
preferred drug list containing the names of drugs for which prior authorization
will not be required under the medical assistance program. All other drugs not
on the preferred drug list, but are in the same drug class as drug(s) placed on
the preferred drug list, shall be placed on an enhanced prior authorization
list. The department may seek the recommendations of an advisory committee to
be comprised of licensed medical and pharmacy professionals regarding the
products that may be placed on a preferred drug list.
(2) The members of the advisory committee
referred to in subsection (b)(1) shall be as determined by the department. The
composition and number of members may change from time to time.
(3) The advisory committee shall meet at
times and locations as may be requested by the department.
(4) The advisory committee's recommendations
may take into consideration all, or some, of the following:
(A) Therapeutic value for the disease or
condition under treatment;
(E) Other considerations as determined by the
committee.
(5) The
advisory committee's recommendation(s) to the department shall be advisory
only. The department may accept or reject all, or a portion, of the
recommendation(s) of the advisory committee.
(6) Pharmaceutical products which have been
placed on a preferred drug list pursuant to the provisions of this subsection
may also be temporarily deleted from the list by the department pending further
review and recommendation of the advisory committee described in section
17-1737-71(b) or the decision of the department. The circumstances under which
the department may temporarily delete a drug from the preferred drug list are
for clinical and safety reasons and administrative cost.
(7) Providers will be notified of changes
made to the preferred drug list.
(c) A request for outpatient drugs, including
prescriptions for nursing facilities, that require prior authorization:
(1) Shall be acted upon within twenty-four
hours of receipt when the request is received within the business week;
or
(2) In an emergency situation,
pharmacies can dispense a seventy-two hour supply of an outpatient drug which
otherwise requires prior authorization under the following conditions:
(A) The consequence of delaying the
dispensing of the drug is a high probability of serious adverse effects on the
person's health. Serious adverse effects are hospitalization, medically
necessary emergency room care, and loss of bodily function or life;
(B) There is no similar medication available
without prior authorization or the patient has a documented intolerance for the
similar agent; or
(C) The patient's
physician documents that the patient is unable to use a generic form of a drug
because of an allergy or history of a serious adverse reaction to the generic
drug.
(d) The
department may require certain medications to be prior authorized or may place
usage restrictions on certain drugs.
(e) Services provided without the required
prior authorizations are subject to denial of payment.
(f) When a request for authorization is
submitted for services which require prior authorization but have already been
rendered, an explanation for the delay in submittal must be provided for
consultant review. If the explanation adequately justifies the untimely
submittal, the request shall be processed in accordance with the procedures
stated in this section. If the explanation does not justify the untimely
submittal, the request shall be denied.
(g) An incomplete prior authorization form
shall be returned to the sender. The form shall be deemed incomplete if the
following is incomplete, illegible or missing. The following are examples and
do not represent an exhaustive list:
(1) The
name and the identification number of the recipient;
(2) The requesting physician's signature,
date, and provider number;
(3) The
supplier's name, provider number, dates of service or period requested as
determined by begin and end dates, and signature, if the service or item is not
being provided by the requesting physician;
(4) The diagnostic code or
description;
(5) The procedure
code; and
(6) For non-urgent
requests, all attached copies of the form must be submitted together intact.
When the newly completed form is received, the form shall be
processed in accordance with the procedures stated in this section from the
date the completed form is received.
(h) When a request for authorization is
deferred due to lack of supportive documentation to justify a service:
(1) The provider(s) shall be notified of the
deferral. The notice shall include a reason for the deferral giving thirty
calendar days from the date of the deferral notice to submit the requested
information; and
(2) If the
requested information is not received within thirty calendar days from the date
of the deferral notice, the request shall be denied; or
(3) If all necessary information is received
within thirty calendar days from the date of the deferral notice, the request
for authorization shall be acted upon within twenty four hours by a DHS
consultant or an authorized representative. If the request is denied, a notice
to include a reason for the denial, shall be sent to the provider(s) and the
recipient.
(j) The
department, through its medical consultants, may permit exceptions and
determine level of care, medical appropriateness, and medical necessity. In
disagreements between the provider and DHS's authorized agent(s) regarding
authorization of services and level of care determinations, the department's
medical consultant's decision shall be final. Further appeal shall be pursued
through the administrative appeals office or the courts.
