Clinical Prior Authorization Evaluation Services
Industry Challenge
Prior authorization (PA) programs manage costs by requiring prescribers to obtain approval before prescribing a non-preferred medication. Automated PA processing systems greatly speed the PA request process and can adjudicate claims that meet the PA processing criteria in seconds. However, some claims fall outside the criteria, require immediate attention, or demand additional clinical review. In these cases, personal clinical evaluation is the best way to ensure that patients remain safe and providers are kept informed.
Solution
|
“The only calls I would get before HID began handling the PA desk were complaints about the level of service; now I only get calls complimenting HID on the prompt service they provide.” -Former Commissioner of Medicaid, State of Alabama |
PA requests are received at the Clinical Help Desk from HID’s online PA submission system, PAXpress™, via fax, or by phone. Once received, each request is processed by a pharmacy technician using a stringent, documented set of criteria established and approved by the client. Requests that involve special circumstances are escalated to the Clinical Help Desk supervisor and then as needed through the following tier of clinicians: registered nurses, PharmD pharmacists, the HID medical director (an experienced MD), and the state medical director for Medicaid; or as designated by the client. The client can also designate any therapies for which PA requests should bypass this escalation process and move immediately to a pharmacist for review. Once the PA request has been processed, the approval or denial is sent back to the MMIS and run through an eligibility checker, which checks the eligibility of the patient, drug, and doctor.
Features
- Clinical expertise. Help Desk personnel are clinically astute. The Help Desk is staffed with pharmacy technicians who have ready access to registered nurses, PharmDs, and physicians. Technicians are nationally certifid unless other credentials are specified by the client.
- Experience. HID has been conducting Help Desk operations for over eight years. With a low rate of turnover, our Help Desk personnel are very familiar with Help Desk procedures and our clients’ needs and workflows.
- Training. All Help Desk personnel are thoroughly trained on each client’s PA algorithms, policies, and procedures.
- Professionalism. HID selects Help Desk personnel for their pleasant personalities as well as their knowledge and expertise. Help Desk staff are trained and expected to be professional and courteous in all dealings with client stakeholders.
- Scalability. HID has two Help Desks: one at our corporate headquarters in Auburn, Alabama and the other in Jackson, Mississippi. Presently, the two Help Desks serve four Medicaid agencies and one commercial client. Both Help Desks have the capability to expand operations as needed.
- Regulation compliance. Each Help Desk processes all PA requests within 24 hours of receiving the request, or as required by the client.
- Thorough reporting package. All transaction details are recorded in the Clinical Help Desk database and can be retrieved for report generation.
Benefits
- Improved patient safety. PA requests that do not meet the criteria are evaluated clinically; patient needs and issues cannot “fall through the cracks.”
- Provider satisfaction. Providers can interact with an experienced technician or clinicians regarding questions on PA requests.
- Ease of submission. HID’s Clinical Help Desks can receive PA requests via online submission using PAXpress, fax, or telephone.
- Integration with automated PA system. The Clinical Help Desk database is integrated with RxPert®, HID’s automated PA system, allowing seamless integration of Help Desk and RxPert operations.
- Electronic access to PA information. Clinical Help Desk functions are conducted electronically and posted in the database. Client staff can use an Internet browser to security access this data and determine the status of any PA request, active or processed, in real time.
For more information on how HID’s Clinical PA Evaluation Services can help your organization, contact us.