1. Prior authorization personnel review the request for prior authorization and apply the clinical guidelines to assess the medical necessity of the prescription.
2. The reviewer may request documentation from the medical record to assess medical necessity.
3. Depending on the reviewer’s determination:
•If the reviewer determines that the request for prior authorization of a prescription meets the medical necessity guidelines, the reviewer authorizes the prescription.
•If the reviewer is unable to determine medical necessity:
•The reviewer refers the prior authorization request to a physician reviewer for a medical necessity determination.
•If necessary, the physician reviewer requests documentation from the medical record to determine medical necessity.
•If, in the professional judgment of the physician reviewer, the services are medically necessary to meet the medical needs of the recipient, the physician reviewer approves the request for prior authorization.
Authorization personnel respond to requests for prior authorization within 24 hours of receiving all information reasonably necessary to make a decision of medical necessity.
Authorization personnel consider requests to authorize multiple refills for a recipient when, in the professional judgment of the reviewer, treatment for the condition is expected to be ongoing. Multiple refills will not exceed a six (6) months or five (5) refill supply (whichever is less) from the time of the original filling of the prescription.
4. Authorization personnel notifies the prescribing physician by return telephone call or fax to indicate whether the request for prior authorization is approved or denied. Authorization personnel also send a written notice of approval or denial of a request for prior authorization to the prescribing physician and the recipient.
5. When authorization personnel approve a request for prior authorization, they issue a 10-digit prior authorization number. This number should be written on the prescription and in the medical record in the event that the prescriber needs to later refer to the number for the patient or pharmacy.