In March 2016, AmeriHealth conducted a year-to-date analysis of specific member satisfaction metrics and discovered that a major cause of frustration among commercial HMO and PPO and Medicare Advantage HMO members arose from providers submitting incomplete prior authorization forms.
Prior authorization requests
AmeriHealth, in conjunction with FutureScripts® and FutureScripts® Secure, provides drug-specific forms for certain drugs that require prior authorization. Completing the necessary prior authorization forms reduces the need for outreach to the physician?s office and helps avoid denials being issued due to lack of information. Drug-specific prior authorization forms are available on the FutureScripts website. Links to this information are also available on AmeriHealth NaviNet® Plan Central in the Administrative Tools & Resources section under Pharmacy Resources. If a drug-specific form is not available, you may submit a General Pharmacy form for commercial members, or a Coverage Determination Request form for Medicare Advantage members.
Incomplete forms
Our analysis showed that members who called to inquire about the status of their coverage determination would often find that the process was delayed as representatives from AmeriHealth or FutureScripts worked to contact providers to obtain missing information.
The following information is commonly missing on the prior authorization forms:
- specific diagnosis
- laboratory values as required by the policy
- specific clinical history as required by the policy
- medication history details (trial and failure of formulary medications)
Timeline for processing requests
For commercial members
The standard coverage determination for commercial members is within two business days. Expedited reviews are available in certain situations.
For Medicare Advantage members
Per the Centers for Medicare & Medicaid Services requirements, a standard Coverage Determination Request form must be completed within 72 hours. All expedited/urgent reviews must be completed within 24 hours. Please reserve all expedited requests for scenarios where the 72-hour standard review timeline may seriously jeopardize the life or health of the enrollee or the enrollee?s ability to regain maximum function.
Considering these tight timelines, incomplete prior authorization forms may hinder care for these members. AmeriHealth or FutureScripts Secure will conduct three good faith outreach efforts, being conscious of office hours, avoiding lunch hours, and leaving messages when possible. However, there are still scenarios where the provider?s office is unavailable, such as on weekends and holidays, or does not return the call within the mandated time frames. This may result in a denied coverage determination, which often could be easily resolved, member inconvenience, and the need to potentially initiate an appeal. Please note that by completing and signing the Coverage Determination Request form, it is critical you be available by phone to discuss potential incomplete information with our medical directors, even on weekends.
For more information on the coverage determination process specific to Medicare Advantage members, please refer to the article Ensuring better drug coverage determination outcomes for you and your patients, found in the June 2015 edition of Partners in Health UpdateSM.
How you can help
As there are profound downstream effects on AmeriHealth members, we strongly encourage providers to thoroughly complete all prior authorization forms and to promptly respond to outreach efforts when there is missing information.
If you have any questions regarding the prior authorization process, please contact Customer Service at 1-888-YOUR-AH1
(1-888-968-7241) for AmeriHealth New Jersey or at 1-800-275-2583 for AmeriHealth Pennsylvania.
FutureScripts and FutureScripts Secure provide pharmacy benefits management services.
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