LOUISIANA MEDICAID PHARMACY BENEFITS
MANAGEMENT PRIOR AUTHORIZATION PROGRAM INSTRUCTIONS
EFFECTIVE JUNE 10,
395 of the Regular Session of the 2001 Louisiana Legislature amends R.S.
46:153.3 (B) and (C) and permits the Department of Health and Hospitals (DHH) to
utilize a prior approval process for its Medicaid prescription drug program
State Fiscal Year 2001, the Louisiana Medicaid Program paid 12,545,632
prescriptions. Between 1995 and
1999, the drug expenditures percentage has risen from 10% to 12% of the total
Medicaid budget. This pattern of
increasing expenditures is projected to continue. Until the current legislative session, Louisiana was prohibited from
utilizing a prescription prior approval process within the Louisiana Medicaid
Program. With the passage of this
legislation, this restriction has been removed, and DHH has elected to implement
a drug Prior Authorization (PA) process.
is utilizing the services of both Gainwell Technologies and the University of Louisiana at
Monroe (ULM), College of Pharmacy to operate the Prior Authorization system. The effective implementation date is June 10, 2002 and will be phased-in
by therapeutic classes.
REQUIRING PRIOR AUTHORIZATION
With the implementation of the Prior Authorization
Program, drugs will be considered "preferred" or "non-preferred". "Non-preferred" drugs will require prior authorization. Listings of these drugs will be
supplied to you prior to the targeted
implementation date for each therapeutic class added to the Prior Authorization
HOW TO OBTAIN PRIOR AUTHORIZATION
authorization is obtained through the University of Louisiana at Monroe (ULM),
College of Pharmacy. Prior
authorizations may be requested by (1) phone, (2) Fax, or (3) mail.
||(1-866-797-2329) Do not send a cover sheet with the FAX.
College of Pharmacy " Rx PA Program
1800 Bienville Drive
Monroe, LA 71201-3765
hours of operation for the ULM Prior Authorization Unit are 8 a.m. to 6 p.m.
Central Time, Monday through Saturday.
(NOTE: The POS Help Desk has NO relationship to the PA Unit or the PA request
WHO CAN OBTAIN PRIOR AUTHORIZATION:
prescribing practitioner is responsible for obtaining prior authorization. (No pharmacist or recipient calls/requests will be accepted.)
(MD & DO, including interns, residents and fellows)
Nurse Practitioners with Prescribing Authority
Nurse Midwives with Prescribing Authority
Clinical Nurse Specialists with Prescribing Authority
The prescribing practitioner must have and provide
his/her valid individual LA Medicaid prescribing provider number to obtain prior
authorization. (Only individual
provider numbers will be accepted.)
HOW TO OBTAIN A PROVIDER NUMBER:
If a prescribing practitioner does not currently have an individual LA Medicaid
provider number, it is important to request a number immediately in order to
prevent prior authorization delays/denials following implementation of the
Contact Gainwell Technologies Provider Enrollment @ 225/923-8510 to obtain a LA Medicaid provider
PA APPROVAL PROCESS: APPROVALS, DENIALS, and VOIDS:
- When a prior authorization request is received, the ULM Prior Authorization Unit has
24-hours from the date and time received to (1) approve, (2) deny, or (3)
void the request. NO retroactive PA approvals will be given.
- A prior authorization
will be approved for a specific period of time with a maximum approval period of
one (1) year. Approvals are not
given based on prescriptions or number of refills. (Example: PA may be given
for a particular drug for a one-year period during which multiple prescriptions
with multiple refills may be written; subsequent prescriptions for the same
authorized drug do not need to be prior authorized so long as the prescription
and refills fall within the one-year period since the drug is authorized for a
period of one year.)
- The prior authorization
prescription time limit and number of refills edit will supercede the
prescription time and refill program limits.
- Example (1): A drug is prior authorized for a period of one (1) month. The prescribing practitioner issues a prescription for 6 months (original
plus five refills). The claim for
the first month dispensed will process and pay based on the one-month
authorization. Any refills
dispensed will deny because there is no authorization for the additional drug.
- Example (2): A drug is prior authorized for a period of twelve (12)
months. The prescriber issues a
prescription for 6 months (original plus five refills). When the prescription refills reach five or 6 months, the prescriber must
issue a new prescription for the remaining 6 months of the authorization, but
does not need a new prior authorization at that time as 6 months of
a request is approved, the prescribing practitioner will be notified by either
phone or fax.
authorization will be established in the PA system and POS claims processing
system to allow claims for authorized medications to process without further
intervention by the pharmacist.
When a request is denied, the prescribing practitioner will be notified by either fax
or written correspondence via first class mail through the U.S. Postal Service.
When a request is voided, the prescribing practitioner will be notified by phone or
fax. Requests will be voided for
the following reasons:
- Incomplete fax or mail
- Fax or mail request not
submitted on the accepted form;
- Phone call is terminated
prematurely by ULM PA staff;
- hone call is terminated
prematurely by requestor;
- hone call is terminated
prematurely for unknown/other reason;
- PA request received from
a non-prescribing practitioner;
- Prescribing practitioner
is not on file;
- Recipient is not on file;
- Drug is not on the
non-preferred drug list;
- Drug is not on file.
MEDICAL REVIEW PROCESS
cases where a prior authorization request is denied, the prescribing provider
may request a phone consultation with a ULM Prior Authorization Unit physician.
final determination (approval or denial) through the ULM Prior Authorization
Unit will be made by the physician consultant within 48 hours following this
phone conference. This decision will be based on the clinical aspects of the
DHH will administer the appeals process.
THE PRIOR AUTHORIZATION FORM(COPY ATTACHED)
FOR PHONE REQUESTS:
- The information on the approved form will be asked verbally for phone requests.
- Information provided must be complete. Incomplete requests will not be processed; they will be voided.
- Phone requests will receive phone responses.
FOR FAXED OR MAILED REQUESTS:
- ONLY the
completed, legible, designated form will be accepted (attached).
- The PA form
should be a single-sheet transmission "DO
NOT include a Cover Sheet".
- Ensure that
the required fields on the form are completed (some fields are required and
some are optional).
- Both the individual provider number and the billing
provider number are requested on the form. Either the Individual Provider
Number (LA Medicaid Prescribing Practitioner"s Provider Number) OR
NPI is required. The billing provider number is optional.
- The form MUST
be signed by the prescribing practitioner (if a stamp is used, the stamped
signature MUST be initialed by the prescribing practitioner).
forms will be returned unprocessed (request voided).
- A faxed or
mailed request will receive a faxed or phone response
(Responses will be mailed only if a fax or phone number is not
indicating emergency situations shall be dispensed in a MINIMUM quantity of a
3-day supply. Refills for the
dispensing of the non-preferred products in these emergency situations are not
permitted. The recipient"s
practitioner must contact the Prior Authorization Unit to request authorization
to continue the medication past the emergency supply, and a new prescription
must be issued.
process may be used when the Prior Authorization Unit is closed (Sundays;
Monday-Saturday before 8 a.m. and after 6 p.m.) or when the PA system is
unavailable. The pharmacist may also use professional judgment in situations
that would necessitate an emergency supply.
The prescribing practitioner must indicate that the
prescription is an emergency Rx on the face of the prescription if hard copy or
if the prescription is called in to the pharmacy, the emergency status of the
prescription must be communicated to the pharmacist who must indicate
"Emergency Rx" on the hard copy prescription. When the pharmacist determines
the prescription is an emergency, the pharmacist must indicate "Emergency by
Pharmacist" on the hard copy prescription. The pharmacist must code the claim
as an emergency prescription (enter "03" in NCPDP Field #487). An NCPDP educational alert will notify the pharmacist that the drug
requires prior authorization.
Recipients are exempt from paying co-payments for emergency situations.
DHH will monitor emergency prescriptions/recipients on an ongoing basis through
management reports, pharmacy provider audits, and other review programs to
review the number of these prescriptions and the reasons for them.
ISSUED PRIOR TO THE IMPLEMENTATION OF PRIOR AUTHORIZATION
prior authorization process will not impact original prescriptions (or refills)
issued by a prescribing practitioner prior to the start date of the Prior
Authorization Process or prior to the effective PA dates of drugs as they are
added to the PA Process. Refills of
prescriptions issued prior to an effective PA date will not be impacted as long
as they are within the 5 refills and 6-month program limits.
Upon implementation of the prior authorization process,
an educational alert will notify the pharmacist that prescriptions issued prior
to this date (and their refills) are
exempt from this process. The
educational alert will state "Drug Requires PA".
PRESCRIPTIONS ISSUED AFTER THE IMPLEMENTATIONOF PRIOR AUTHORIZATION
the implementation of the prior authorization process, if a recipient elects to
self-pay for an original prescription, then attempts to have Medicaid pay for a
refill of the prescription for a drug requiring PA, the pharmacy claim for the
refill will be denied for lack of an approved authorization.
- If an
approved prior authorization exists in the system, the pharmacy claim will
pass the PA edit and continue with existing POS edits. If an approved prior authorization does not exist, the pharmacy claim
will be denied through the POS system.
- An approved
prior authorization does not guarantee payment of the claim by Medicaid. It only indicates that the drug has been approved as a course of
treatment within the Medicaid Program. All existing POS claim edits will continue to be applied.
- The prior
authorization process does not verify recipient Medicaid eligibility. It only verifies that the recipient is "on file" (i.e., has a
valid Medicaid ID number on file " not that the recipient is eligible on
the date of service). Recipient
eligibility will continue to be verified by the Pharmacy POS subsystem or
through the MEVS or REVS automated recipient eligibility systems.
dispensing prescriptions for recipients with retroactive Medicaid
eligibility, the pharmacist must file these claims hard copy for special
handling. These claims should
be sent to:
Bureau of Health Services Financing
P.O. Box 91030
Baton Rouge, LA 70821
- With the implementation
of the Prior Authorization Process, only practitioners" individual prescriber
numbers will be accepted to request prior authorization of a non-preferred drug. Any provider number other than an individual prescribing provider number
WILL NOT be accepted to prior authorize non-preferred drugs.
- In he past, pharmacies were allowed to use the provider numbers of hospitals,
clinics, etc., as prescriber numbers for claims processing purposes. At this time, prescriber numbers other than individual provider numbers
will be accepted through the POS system for claims involving drugs that do not
require prior authorization. This
exception will be phased out, effective July 2002. At that time, only individual prescribing provider numbers will be
accepted for processing and paying all pharmacy claims.
PHARMACY PA and PRESCRIBER NUMBER POS EDITS
||New RX Will Require PA after DATE
||PA Required " MD Must Call ULM Operations
||PA Expired " MD Must Call ULM Operations
||Emergency Override of a Drug That Requires PA
||Provider Type Not Authorized to Prescribe
||Prescriber Number Not For Individual