Prior Authorization Task Force update

Friday, November 01, 2013 12:38 PM

Prior authorization working group plans the process

Marilyn Rissmiller, Senior Director, Health Care Financing

The Colorado legislature passed the prior authorization reform bill, or Senate Bill 13-277, in 2013 to establish a standardized prior authorization process for prescription drugs. CMS strongly supported the bill, which works to streamline the administrative process and improve patient care by allowing physicians and other providers to devote less time to administrative duties and more time to patient care.

As mandated in the legislation, the Department of Regulatory Agencies, including the Division of Professions and Occupations and the Division of Insurance, formed the prior authorization working group this summer to develop recommendations for how the prior authorization process will work.

Membership includes physicians, dentists, nurses, practice administrators, Colorado Medical Society staff, health plans, pharmacy benefit managers (PBMs), pharmacies and drug manufactures. We are meeting monthly in order to submit our recommendations to the Division of Insurance by Dec. 15.

The law outlines several requirements that must be part of the prior authorization process:

• It must be available electronically, but electronic filings are not required.
• Carriers and pharmacy benefit managers (PBMs) must provide certain information on their websites.
• Carriers must use evidence-based guidelines.
• Providers may submit requests electronically.
• A notice of approval to the provider must include a unique prior authorization number, particular drug approved, date for next review and a link to criteria the provider will need to submit for re-approval.
• A notice of denial to the provider must include appeal rights.

As of our October meeting we are considering five main elements to the process: transparency, timeliness, communication, electronic transactions and consistency of criteria. We want notification to be timely and to limit unnecessary back-and-forth communications between the physician, plan and/or PBM. We also want to ensure the availability of complete information on the plan’s prior authorization requirements, and to ensure consistency between the prior authorization process and basic requirements for the same medications among plans.

Once we submit our recommendations, the commissioner of DOI will consider them in concert with national standards for electronic prior authorization, whether the process should require certain clinical criteria be reviewed, whether the process should require a review of local coverage determinations and specialty society guidelines, and whether the process should include a method that leads to immediate determination. The DOI will also develop a standard prior authorization form.

The commissioner will develop the final process and form by July 31, 2014, and it will go into effect by Jan. 1, 2015.