States Are Increasingly Turning to Uniform Prior Authorization Forms

Background

Prior authorization is a common tool for utilization management and controlling health care costs. While the approach to the process is similar across payers, each insurance carrier and public program has its own forms – with variations on questions asked, how they are asked, and the order in which they are asked – and processes for submitting and processing those forms. Health care providers report that these payer-specific forms and processes create administrative burden and delay needed treatments.

A growing number of states are implementing uniform prior authorization forms to limit the amount of information that carriers may require to process prior authorization requests–and to create a standard form that providers can use for all such requests, rather than having to use a different form for each insurer.

National Context

More than 10 states have adopted uniform prior authorization forms to date. This includes California [1],Colorado [2], Florida [3], Hawaii [4], Indiana [5], Louisiana (form under development), Massachusetts [6], Michigan [7], Minnesota [8], New Hampshire [9], New Mexico [10], Oregon [11], and Texas [12]. Three of these states – Florida, Louisiana, and New Hampshire – have adopted these requirements since the start of 2017, and Illinois has a bill currently pending [13].

Most of these states have a uniform prior authorization form and requirements in place only for prescription drug prior authorization requests. However, Florida, Indiana, Massachusetts, and Texas also have uniform prior authorization forms for other medical services.

The standard state forms currently in place have some similarities as far as content. Most are one to two pages, and the uniform prior authorization forms for prescription drugs generally require the following information:

• Information about the request, including whether it is a new request and whether it is urgent;
• Basic identifying information about the patient and his / her insurance coverage;
• Basic identifying information about the prescriber, as well as the provider’s National Provider Identifier, Drug Enforcement Administration number, and specialty;
• Information about the prescription drug being requested, including information such as dosage / strength, frequency, length of prescription, quantity, and administration type and location;
• Information about the patient’s diagnosis and other medications used or prescribed previously; and
• A justification of the request and a general request for other information.

Despite these similarities, there is no national model to follow, and each state has adopted some variation in its uniform prior authorization form for prescription drugs. For example, the following information is requested on some standard forms, but not consistently:

• Information about an authorized representative;
• Information about the filling pharmacy;
• Broader health information, including the patient’s height, weight, and allergies;
• Requirements for clinical information (such as symptoms, labs, and contraindications);
• Information specific to the following types of drugs: those that are part of a clinical trial; compound drugs; provider-administered drugs; and drugs being prescribed for off-label uses; and
• Information specific to opioid management.

Additionally, some but not all states have created several variations of their forms specific to particular drugs, or allow carriers to use their own form or request additional information for certain drugs. A few of the states also exempt carriers that use electronic prior authorization.

Similarly, the common features among state uniform prior authorization forms for medical services include:

• Information about the request, including whether it is a new request and whether it is urgent;
• Basic identifying information about the patient and his / her insurance coverage;
• Basic identifying information about the prescriber, as well as the provider’s specialty;
• The type of service being requested and information about the service itself, including where it will be delivered; and
• Clinical information, including the diagnosis code and medical necessity.

As with the forms for prescription drugs, however, no two states utilize the same model. In particular, the state forms vary in relation to:

• Whether they request information about the primary care physician; and
• Whether specific clinical documentation is required, including documenting provider visits, symptoms, labs, medical history, and other treatments tried.

Additionally, some states with standard forms for prior authorization for medical services have created service-specific forms or included questions specific to the service type.

Recommendations

Creating uniform prior authorization forms hold significant promise as a feasible way to minimize provider burden and ensure appropriate access to prescription drugs. Though a number of states have successfully pursued such forms, there is not a one-size fits all model nationally. Likewise, there are a wide range of forms currently in use by private insurers.  To successfully implement standard forms, states must take into account state-specific considerations, and strike the right balance between minimizing administrative burden on providers requesting prior authorization and addressing the information needs of carriers. This will ensure that time-consuming follow-up and/or unnecessary denials do not result.

PCG Health subject matter experts offer the following recommendations:

• Look to statutes enacted in other states. Unlike the standard forms that vary across states, there is significant similarity in the authorizing statutes (in particular in mandating maximum length, development process, and availability of the form). States drafting authorizing legislation should look to those models.
• Consider ancillary requirements and alternative approaches. For example, many of the state authorizing laws for uniform prior authorization forms include standards that accompany the standard form, including: transparency requirements regarding sharing forms and approval criteria; maximum timelines for responding to prior authorization requests and content requirements for prior authorization responses; minimum duration of approvals; requirements regarding use of electronic prior authorization (ePA) and / or exempting carriers who use ePA from adhering to the standard form; exemptions for certain drugs or drug specific forms; requirements regarding the use of evidence-based guidelines; and enforcement provisions. Some state authorizing laws specifically allow carriers to request additional information, while others prohibit doing so and require that the form be the entirety of the informational requirements. Alternatives adopted in other states include: requiring use of ePA; requiring carriers to honor prior authorizations of the previous carrier during coverage transitions; requiring approval of carrier-specific prior authorization forms; and creating standards for prior authorization.
• Consider applicable existing statutory and regulatory parameters. States must consider whether there are existing laws or regulations in place that will dictate the structure and content of the form.

Further, states interested in undertaking a uniform prior authorization endeavor should plan to undertake a comprehensive process. There are proven best practices in pursuing such an initiative and lessons learned that should guide states’ approach:

• Compare the forms currently in use in the state (by insurers, Medicaid, and Medicare). Via a stakeholder-engaged process (as outlined below), the state can request all forms from carriers and / or local providers. These should then be reviewed and systematically cataloged to guide the state’s decision-making process about the structure and content of the standard form. In particular, the state should look to the common trends in forms in use in the state for indication of what information is widely considered necessary to process prior authorization requests.
• Look to national examples. While there is no consistent approach, states should consider the forms in use in other states, and should reach out to local counterparts – particularly states that share local insurers. States should also look to national standards for electronic prior authorization.
• Most if not all states that have undertaken this process have utilized a stakeholder process to inform their work. In order to balance the forms currently in use in the state and the standard forms that have been adopted across the country, regulators need to hear from providers (regarding their challenges) and carriers (regarding their approval process and criteria and why their forms are structured as they are). The state should be guided by how the process is currently performed, and should ideally work on the ground. Undertaking a stakeholder process will allow the state to balance the informational needs of carriers with the time required of providers and create a form with as much consensus as possible. The state should also engage ePA trade organizations to ensure the form is structured in a way that can be facilitated via an electronic process. A stakeholder-engaged process will also aid in paving the way for as seamless an implementation process as possible.
• The form must be accompanied by guidance and instructions. To ensure appropriate use, the state should enact regulations dictating use, and the form should be accompanied by clarifying instructions.

PCG Health has assisted states undertaking this process. For more information, contact Lisa Kaplan Howe at lkaplanhowe@pcgus.com.

Footnotes:

[1] http://wpso.dmhc.ca.gov/

[2] https://www.sos.state.co.us/

[3] https://www.flrules.org/

[4]http://www.alohacare.org/

[5]https://www.in.gov/

[6]  https://www.mass.gov/

[7] https://www.michigan.gov/

[8] http://www.health.state.mn.us/

[9] https://www.nh.gov/

[10] http://www.osi.state.nm.us/

[11] https://dfr.oregon.gov/

[12]  http://www.tdi.texas.gov/

[13] http://www.ilga.gov/