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Updates From DPW: Prior Authorization and Others
March 1, 2013

The Department of Public Welfare (DPW) has released the following information.

Comment on Proposed Prior Authorization Requirements and Medical Necessity Guidelines for Therapeutic Duplication
The Office of Medical Assistance Programs (OMAP) has issued Proposed Prior Authorization Requirements and Medical Necessity Guidelines for Therapeutic Duplication, for drug classes that include Typical Antipsychotics for review and comment. Grandfathering requirements are changed. The changed language establishes that grandfathering does not apply to “…all prescriptions for antipsychotics that are therapeutic duplications, or to prescriptions for a preferred or non-preferred oral atypical antipsychotic for recipients 18 years of age and older when prescribed in a low-dose range beyond the first 60 days of therapy.”

The threshold for prior authorization is changed to require prior authorization when the recipient is taking two or more medications from the same therapeutic drug class for 60 or more consecutive days. 

Review the entire guideline at the DPW Medical Assistance (MA) Advisory Committee Archive web page. OMAP requests comments in Microsoft Word documents to c-crussell@state.pa.us by March 14.

Recent MA Bulletins
Bulletin Number 08-13-10, Medical Assistance Electronic Health Record (EHR) Incentive Program Year 2013 for Eligible Professionals (EP) was issued in February and effective January 1. The bulletin provides information about changes to the MA EHR Incentive Program stages one and two meaningful use requirements; identifies participation requirements for attestations submitted for program year 2013; and relates these requirements to payment years 1-3. Eligible professionals must be registered with the Centers for Medicare and Medicaid Services (CMS) Registration and Attestation to receive payments. Application for the second payment year must be made through the PROMISe Provider Portal. Beginning in Program Year 2013, stage one meaningful use objectives, measures, and exclusions will be changed, but the changes will not be available in the Medical Assistance Provider Incentive Repository until April 1. Other changes to stage one meaningful use will not occur until Program Year 2014. Eligible professionals can attest to stage two meaningful use in Program Year 2014. Stage three meaningful use has yet to be defined. For more information please review the bulletin.

Bulletin Number 99-13-05, Continued Existence of the Fee-/for-Service (FFS) Delivery System in HealthChoices Zones and Enrollment of Brest and Cervical Cancer Prevention and Treatment (BCCPT)Recipients in HealthChoicesreminds providers that the FFS delivery system will continue to operate in all HealthChoices zones and that beginning March 1 individuals who are eligible under BCCPT will be enrolled in HealthChoices managed care organizations. Certain populations will continue to use the ACCESS card to receive services through FFS. These include dual eligible individuals, those newly eligible for MA waiting for enrollment in an MCO, and individuals who are admitted to a state operated facility, among others. Review the bulletin for more complete information.  

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