These requirements and procedures for requesting prior authorization should be followed to ensure accurate and timely processing of prior authorization requests. Providers may obtain additional information by calling the Pharmacy Services call center at 1-800-537-8862 during the hours of 8 AM to 4:30 PM Monday through Friday. Show
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Prescriptions That Require Prior AuthorizationPrescriptions that meet any of the following conditions must be prior authorized
5-Day Supplies Without Prior AuthorizationIf a prescription requires prior authorization and the beneficiary has an immediate need for the prescribed drug, the Department will allow the pharmacy to dispense a 5-day supply of the drug without prior authorization at the discretion of the dispensing pharmacist. Pharmacists should use their professional judgment to determine if the beneficiary has an immediate need for the drug. Pharmacists may choose to not fill a 5-day supply of a drug if the pharmacist determines that taking the drug alone or in combination with the beneficiary's other drugs may jeopardize the health and safety of the beneficiary. When filling a prescription for a 5-day supply, the dispensing pharmacy should bill the prescription for a quantity sufficient for a 5-day supply based on the prescribing provider's directions. The pharmacy must enter a "3" in the Level of Service field in the pharmacy dispensing system. Five-day supplies may not be dispensed in a limited number of circumstances. Refer to the Prior Authorization Clinical Guidelines relating to the specific drug or class of drugs for
more information. Back to Table of Contents Initiating the Prior Authorization Request Who May Initiate a Request Initiating a Request by Phone Initiating a Request by Fax The prescribing provider must submit the completed, signed, and dated prior authorization fax form and the required supporting clinical documentation of medical necessity by fax to 1-866-327-0191. This fax number is also printed on the top of each prior authorization fax form. Back to Table of Contents Basic Information Required for the Prior Authorization RequestThe basic information required at the time prior authorization is requested includes the following:
Clinical Documentation Supporting the Medical Necessity of a Prescription That Requires Prior AuthorizationPrescribing providers must submit clinical documentation to support the medical necessity of the requested drug for the beneficiary. Examples of appropriate clinical documentation include chart or clinic notes, laboratory test results, and diagnostic test results (e.g., radiographs, MRIs, etc.). Refer to the Prior Authorization Clinical Guidelines relating to the specific drug or corresponding class of drugs for details regarding the information required to process the prior authorization request. The clinical information submitted with the prior authorization request must be verifiable within the beneficiary's medical record. Upon retrospective review, the Department may seek restitution for the payment of the prescription and any applicable restitution penalties from the prescriber if the medical record does not support the medical necessity of the drug. (See 55 Pa. Code §
1101.83(b)). Back to Table of Contents Submitting the Prior Authorization RequestFor prior authorization requests initiated by phone, the prescribing provider must submit the required supporting clinical documentation of medical necessity by fax to 717-265-8289. This fax number will also be provided by the Pharmacy Services coordinator over the phone when initiating the request. For prior authorization requests initiated by fax, the prescribing provider must submit the completed, signed, and dated Prior Authorization Form and the required supporting clinical documentation of medical necessity by fax to 1-866-327-0191. This fax number is also printed on the top of each prior authorization fax form.
Back to Table of Contents Clinical Review ProcessPrior authorization personnel will review the request for prior authorization and apply the Prior Authorization Clinical Guidelines relating to the specific drug or corresponding class of drugs to assess the medical necessity of the requested drug. If the reviewer determines that the request meets the prior authorization guidelines, the reviewer will prior authorize the prescription. The reviewer may request additional documentation from the beneficiary's medical record to assess medical necessity. (See 55 PA Code § 1101.51(d) and (e)). If the reviewer is unable to
determine medical necessity or if the request does not meet the prior authorization guidelines, the prior authorization request will be referred to a physician reviewer for a medical necessity determination. The physician reviewer may request additional documentation from the beneficiary's medical record to assess medical necessity. (See 55 PA Code § 1101.51(d) and (e)). Such a request for prior authorization may be approved when, in the professional judgment of the physician reviewer, the
services are medically necessary to meet the medical needs of the beneficiary. Back to Table of Contents Automated Prior Authorization ApprovalsA prescription for a drug that requires prior authorization with a prescribed quantity that does not exceed the quantity limit established
by the Department will be automatically approved when the Department's Point-of-Sale On-Line Claims Adjudication System verifies a record of a paid claim(s) verifying that the guidelines to determine medical necessity have been met. Automated Prior Authorization Approvals and Guidelines to Determine Medical Necessity are noted in the Prior Authorization
Clinical Guidelines relating to the specific drug or class of drugs. Back to Table of Contents Dose and Duration of TherapyThe Department will consider requests to authorize multiple fills for a beneficiary when, in the professional judgment of the reviewer and in
accordance with the Dose and Duration of Therapy in the Prior Authorization Clinical Guidelines relating to the specific drug or class of drugs, treatment for the condition is expected to be ongoing.
Back to Table of Contents Timeframe of ReviewThe Department will respond to requests for prior authorization within 24 hours of receiving all information reasonably necessary to make a decision of medical necessity.
Back to Table of Contents Notice of DecisionThe Department will notify the prescribing provider by return telephone call or fax indicating whether the request for prior authorization is approved or denied. The Department will also send a written notice of approval or denial of a request for prior
authorization to the prescribing provider and the beneficiary by mail. Back to Table of Contents Denials and AppealsIf the request to approve a prescription that requires prior authorization is denied or approved other than as requested, the beneficiary has the right to appeal the
Department's decision. The beneficiary has 30 days from the date of the prior authorization notice to submit the appeal in writing to the address listed on the notice. If the beneficiary has been receiving the drug that is being reduced, changed, or denied and an appeal is hand-delivered or postmarked within 10 days of the date of the notice, the Department will authorize the prescription for the drug until a decision is made on the appeal. Refer to the
Hearings and Appeals Process for more information. Back to Table of Contents Which of the following is the most ideal approach to refusing requests?Which of the following is the most ideal approach to refusing requests? Find a fair and reasonable explanation for your refusal.
Which of the following should you do when making your case for refusal?Which of the following should you do when making your case for refusal? Explain your company's relevant policy. When making your case for refusal you should explain your company's relevant policy. When paired with the relevant facts, they should lead logically to the conclusion that you cannot grant the adjustment.
Which of the following guidelines should be followed when delivering messages that carry bad news?Which of the following guidelines should be followed when delivering messages carrying bad news? Deliver facts positively without confusing or misleading the reader.
Which of the following outcomes is associated with the direct method of refusing a request?Which of the following outcomes is associated with the direct method of refusing a request? Readers have an immediately negative impression.
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