Updates to prior authorization form for prescription medications and new timelines for response now in effect On July 1, 2017, two new laws affecting the standardized prescription drug prior authorization form took effect. SB 282 required the Department of Managed Health Care (DMHC) and the Department of Insurance to create a standard electronic prior authorization request form. A second related law (AB 374) required the agencies to include on the updated form the option for physicians to request an exception to the plan/insurer’s step therapy process. Previously, SB 866 had required use and acceptance of a paper uniform prior authorization form. The form was updated in December 2016 and effective July 1, 2017, prescribers and payors are now required to use and accept this uniform prior authorization form, available on the DMHC website. Step therapy exception requests are to be submitted in the same manner as a request for prior authorization for prescription drugs, and would require the plan or insurer to treat, and respond to, the request in the same manner as a request for prior authorization for prescription medications. SB 282 also modified the timeframes in which plans/insurers are required to respond to the prior authorization/step therapy requests. Previously, plans/insurers were required to respond within two business days. SB 282 now requires plans/insurers to respond within 72 hours for nonurgent requests and within 24 hours for urgent requests. If a plan or insurer fails to respond within those timeframes, the request is deemed approved. The new law does not expand the list of medications that require a prior authorization. Delegated physician groups do not have to use the standardized form if they have been delegated the financial risk for prescription drugs and do not use a prior authorization process. September 25, 2017 General Drug Prescribing, Preauthorization, Prescription Drugs 0 0 Comment Read More »
Large insurers drop barriers to prescribing medications for opioid use disorder Three of the nation's largest insurers—Aetna, Cigna, and Anthem Blue Cross—have in recent months announced that they will no longer require physicians to seek prior approval before prescribing medication to treat opioid use disorder. These policy changes come as more than 2.2 million people meet the diagnostic criteria for an opioid use disorder. Treatment of opioid use disorder with opioid maintenance therapies has been shown to be cost-effective, safe and successful when used appropriately. Increasing access to treatment is crucial to addressing opioid misuse and overdose, and the California Medical Association urges all insurers to make patient care a priority over administrative hurdles. Prior authorization often has a negative impact on patient care when there is a delay or interruption in ongoing treatment due to a health plan utilization authorization. According to the American Medical Association, 75 percent of surveyed physicians described prior authorization burdens as high or extremely high. More than a third of physicians reported having staff that work exclusively on prior authorization. Nearly 60 percent of physicians reported that their practices wait, on average, at least one business day for prior authorization decisions, and more than 25 percent of physicians said they wait three business days or longer. Contact: Samantha Pellon, (916) 551-2887 or spellon@cmanet.org. March 2, 2017 General Aetna, Anthem Blue Cross, Cigna, Opioids, Preauthorization 0 0 Comment Read More »
UHC to require prior authorization for select outpatient surgical procedures As indicated in its July 2015 Network Bulletin, United Healthcare (UHC) will begin requiring prior authorization for certain surgical procedures done in a hospital outpatient setting effective October 1, 2016. The new prior authorization requirement includes procedure codes in cardiovascular, cosmetic and reconstruction, ophthalmology, and ENT (ear, nose and throat) specialties. Prior authorization will not be required to perform the identified procedures if done in an in-network ambulatory surgery center. For a complete listing of procedures requiring prior authorization, physicians can access the Prior Authorization for Outpatient Surgical Procedures FAQ on the UHC website. Practices may submit prior authorization requests to UHC via the www.UnitedHealthcareOnline.com website, by calling (877) 842-3210 or by faxing the request to (866) 756-9733. For questions or concerns regarding this process, physician practices should contact UHC Network Management at (866) 574-6088. August 9, 2016 Managed Care United Healthcare, Preauthorization 0 0 Comment Read More »
UHC to require prior authorization for select musculoskeletal and pain management procedures As indicated in its January 2015 Network Bulletin, United Healthcare (UHC) will begin requiring prior authorization for certain additional musculoskeletal and pain management procedures effective April 4, 2016. Included in the new prior authorization requirement are various arthroscopy procedures, spine-related surgeries, neurostimulators for back pain and certain foot surgical procedures. For a complete listing of procedures requiring notification, physicians can access the Advance Notification Requirements on the UHC website. Prior authorization will be required for services performed in all places of service settings, including inpatient/outpatient hospitals, ambulatory surgery centers and office locations. Practices may submit prior authorization requests to UHC via the www.UnitedHealthcareOnline.com website, by calling (877) 842-3210(877) 842-3210 FREE or by faxing the request to (866) 756-9733 FREE. For questions or concerns regarding this process, physician practices should contact UHC Network Management at (866) 574-6088 FREE. Call Send SMS Call from mobile Add to Skype You'll need Skype CreditFree via Skype February 9, 2016 General, Managed Care Preauthorization, United Healthcare, Pain Medicine 0 0 Comment Read More »
New approval timeframes for prescription drug prior authorizations took effect Jan. 1 A new law took effect Jan. 1, 2016, that requires health plans and health insurers to respond to prescription drug prior authorization requests within 72 hours for non-urgent requests and 24 for urgent requests. The law (SB 282) deems such requests to be granted if the payor fails to respond within these timeframes. A previous law (SB 866) had required a determination within two business days or the request was deemed approved. SB 282 also requires the Department of Managed Health Care and the Department of Insurance to create a standard electronic prior authorization request form no later than Jan. 1, 2017. Prescribers and payors will be required to use and accept this uniform electronic prior authorization form beginning July 1, 2017, or 6 months after the form is developed, whichever is later. Previously, SB 866 had required use and acceptance of a paper uniform prior authorization form. A second and related law (AB 374) requires that prior authorization for prescription drug step therapy override requests be submitted in the same manner—and using the same electronic form, when available—as a prescription drug prior authorization requests. Plans and insurer must also respond to such requests within the timeframes set forth in SB 282. Contact: CMA's reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org. January 15, 2016 General Department of Managed Health Care, Preauthorization, Prescription Drugs, Department of Insurance 0 0 Comment Read More »
New prescription drug prior authorization form required on Jan. 1 for DMHC regulated products On January 1, 2015, a new law will fully take effect that streamlines and standardizes the prior authorization process for prescription drugs. The law (SB 866) requires all insurers, health plans (and their contracting medical groups/IPAs) and providers to use a standardized two-page form for prior authorizations of prescription medications. The law also requires plans and insurers to make a determination on prescription drug prior authorization requests within two days of receipt, and if they fail to do so the requests will be deemed authorized. The new law does not expand the list of medications that require a prior authorization. The Department of Managed Health Care (DMHC) and the Department of Insurance (DOI) jointly developed the standardized authorization form and implementing regulations. The two agencies, however, are enforcing the regulations on different timetables. The regulation for DMHC regulated products, which includes all HMOs, their contracting medical groups/IPAs and most Blue Cross and Blue Shield PPOs, becomes effective January 1, 2015. However, the regulation for DOI regulated products, including all other PPOs and the Blue Cross and Blue Shield Life & Health products took effect on October 1, 2014. Practices using EHR systems that incorporate plan/insurer and medication specific forms for prescription drug prior authorizations are encouraged to contact the vendors about how they are accommodating this change. Click here to access the new form. The form (Form No. 61-211), which is also available on the payor websites, can be submitted via paper, electronic transmission, fax, web portal or another mutually agreeable method. For more information on the new form and accompanying regulations, including a chart of the effective dates by payor and product, see the California Medical Association (CMA) physician FAQ, “A Physician’s Guide to Implementation of SB 866: The new standardized prescription drug prior authorization form.” This document is available free to members. Practices that run into any problems with the form itself — integration into an EHR, submission of the form, multiple requests for medical records from payors, delays in processing, etc. — are encouraged to contact CMA at (888) 501-4911 or economicservices@cmanet.org to share your experience. December 16, 2014 General, Managed Care Prescription Drugs, Preauthorization 0 0 Comment Read More »
CMA wants to hear from practices experiencing problems with the new prescription drug prior authorization form A new law recently took effect that streamlines and standardizes the prior authorization process for prescription drugs for most patients with PPO products. The new law (SB 866) requires all insurers, health plans (and their contracting medical groups/IPAs) and providers to use a standardized two-page form for prior authorizations of prescription medications. The law also requires plans and insurers to make a determination on prescription drug prior authorization requests within two days of receipt. If they fail to do so, the requests will be deemed authorized. The new law does not expand the list of medications that require a prior authorization. The requirement for HMO products, including Anthem Blue Cross and Blue Shield of California, becomes effective on January 1, 2015. The regulation for Department of Insurance-regulated products, including all other PPOs and Blue Cross and Blue Shield Life & Health products, became effective on October 1, 2014. However, in an effort to avoid confusion for practices, many plans/insurers implemented the new form across most, if not all, of their product lines on October 1. The California Medical Association (CMA) is interested in hearing from practices that have experienced difficulties with the new form. If your practice has run into any problems with the form itself, integration into your EHR, submission of the form to the payor, multiple requests for medical records from the payor, delays in processing by the payor, etc., please contact CMA at (916) 551-2061 or economicservices@cmanet.org to share your experience. For information on the new form and accompanying regulations, including a chart of the effective dates by payor and product, see the CMA physician FAQ, “A Physician’s Guide to Implementation of SB866: The new standardized prescription drug prior authorization form.” This document is available free to members. November 14, 2014 Managed Care Prescription Drugs, Preauthorization 0 0 Comment Read More »
Are you ready for the new prescription drug prior authorization form required on October 1? Over the next several months, a new law will take effect that streamlines and standardizes the prior authorization process for prescription drugs. The new law (SB 866) requires all insurers, health plans (and their contracting medical groups/IPAs) and providers to use a standardized two-page form for prior authorizations of prescription medications. The law also requires plans and insurers to make a determination on prescription drug prior authorization requests within two days of receipt, and if they fail to do so the requests will be deemed authorized. The new law does not expand the list of medications that require a prior authorization. The Department of Managed Health Care (DMHC) and the Department of Insurance (DOI) jointly developed the standardized authorization form and implementing regulations. The two agencies, however, will be enforcing the regulations on different timetables. The regulation for DMHC regulated products, which includes all HMOs, their contracting medical groups/IPAs and most Blue Cross and Blue Shield PPOs, becomes effective January 1, 2015. However, the regulation for DOI regulated products, including all other PPOs and the Blue Cross and Blue Shield Life & Health products become effective on October 1, 2014. The lack of synchronicity in the effective dates has the potential to cause confusion for practices, particularly those who treat patients with Anthem Blue Cross PPO or Blue Shield of California PPO products, as it can be difficult to determine whether the patient has a DOI regulated product, a DMHC regulated product or a product that is regulated out-of-state (i.e., Blue Card product). However, in an effort to avoid confusion for practices, some plans/insurers are implementing the new form across most, if not all, of their product lines on October 1. There are exceptions, however, so practices are encouraged to review the payor notices and to call payors with any specific questions they may have. Links to the payor notices that were available at the time of publication are below: Aetna (not available) Anthem Blue Cross Blue Shield of California Cigna Health Net United Healthcare (not available) Click here to access the new form. The form (Form No. 61-211) will also be available on the payor websites by October 1 and can be submitted via paper, electronic transmission, fax, web portal or another mutually agreeable method. For more information on the new form and accompanying regulations, including a chart of the effective dates by payor and product, see the California Medical Association physician FAQ, “A Physician’s Guide to Implementation of SB866: The new standardized prescription drug prior authorization form.” This document is available free to members. September 22, 2014 General Drug Prescribing, Preauthorization, Prescription Drugs 0 0 Comment Read More »
Change in prior authorization form for prescription medications becomes effective October 1 Over the next several months, a new law (SB 866) will take effect that streamlines and standardizes the prior authorization process for prescription drugs. The new law requires all insurers, health plans (and their contracting medical groups/IPAs) and providers to use a standardized two-page form for prior authorizations of prescription medications. Additionally, if a health plan or insurer fails to use or accept the prior authorization form, or fails to make a determination within two business days, the prior authorization request is deemed approved. Currently, plans have five business days in which to make a determination, while practices are often forced to sort through hundreds of different prior authorization forms to locate the one needed. The new law does not expand the list of medications that require a prior authorization, but for those medications where a prior authorization is required, prescribing physicians must submit (and plans and insurers must accept) the new standardized two-page form. Please note the two-page form only applies to medication prior authorization requests; it does not apply to requests for authorization of procedures. The Department of Managed Health Care (DMHC) and the Department of Insurance (DOI) jointly developed the standardized authorization form and implementing regulations with stakeholder input. The two agencies, however, will be enforcing the regulations on different timetables. The regulation for DMHC-regulated products, which includes all HMOs, their contracting medical groups/IPAs, and most Blue Cross and Blue Shield PPOs, becomes effective January 1, 2015. However, the regulation for DOI-regulated products, including all other PPOs and the Blue Cross and Blue Shield Life & Health products, becomes effective on October 1, 2014. The form (No. 61-211) will be available on the plan and insurer websites as well as the regulators’ websites soon, and can be submitted via paper, electronic transmission, telephone, web portal or another mutually agreeable method. Anthem recently notified practices that it is streamlining the process by requiring use of the form for all product types on October 1. The California Medical Association (CMA) has asked Blue Shield for details about how it plans to implement and is waiting to hear back. CMA is in the process of developing a physician resource sheet on the new law and will publish when it’s completed. September 4, 2014 General Advocacy, Prescription Drugs, Preauthorization 0 0 Comment Read More »
