Attachment G.14 - 016_TGD_RetrospectiveAuthorizations_TGD_Final.pdf

Contractor Technical Guidance Document

TGD #016

Retrospective Authorization Requirements for Level 3 Prior Authorizations Related to Medical

Services

ISSUED DATE: March 29, 2021 EFFECTIVE DATE: March 29, 2021

Purpose On January 14, 2021, the Program sent instructions to the CCE/NPN Clinical Directors clarifying requirements to adhere to retrospective timeframes, along with a process to administratively close any non-compliant PA-3 submissions.

The purpose of this guidance is to provide clarification of requirements for submission of retrospective level 3 Prior Authorization (PA) requests for medical services and to provide clarification on the process for handling non-compliant PA-3 submissions. This guidance expands the requirements in the Administrative Manual and the previously provided guidance sent to the CCE’s/NPN on January 14, 2021.

This Technical Guidance Document does not apply to those Level 3 Prior Authorizations which are administratively closed due to missing information. Those requests may be resubmitted if and when that information becomes available.

Stakeholders affected The requirements in this Technical Guidance Document apply to the Clinical Centers of Excellence (CCEs), Nationwide Provider Network (NPN), and William Street Clinic (WSC).

Background1 Certain medical services and devices have limited use guidelines and/or require Prior Authorization (PA).

Brief guidelines, including those related to PAs, are listed in the Codebook, and direct the treating provider to use services in limited or specific clinical situations that align with the Program’s limited health plan model. These guidelines will designate specific services as requiring a Level 2 Prior Authorization (PA2) or a Level 3 Prior Authorization (PA3). The CCE/NPN Clinical Director is liable for all PA2/PA3 decisions.

PA2 requests require authorization by the CCE/NPN Clinical Director. This authorization includes the documentation of medical necessity, attestation of meeting clinical criteria2, and approval by the CCE/NPN Clinical Director. This documentation and approval must be maintained either in the member’s

1 See the WTC Health Program’s Administrative Manual, Chapter 4 – Section 3.4 at https://www.cdc.gov/wtc/ppm.html#medical_prior.

2 Some services may have a Medical Coverage Determination (MCD) with specific authorization criteria that the member must meet in order to receive applicable services.

https://www.cdc.gov/wtc/ppm.html#medical_prior medical record or other CCE/NPN tracking systems and be easily retrievable. All PA2 documentation is subject to audit.

PA3 requests require authorization by NIOSH. Some services which require a PA3 have a Medical Coverage Determination (MCD) with specific guidance on use and limitations. The CCE/NPN Clinical Director must submit a PA3 request to the NIOSH for any service or device that lists PA3 as a requirement in the Codebook. When there is an urgent need for the medical service, the CCE/NPN Clinical Director may submit a PA3 request for the services retrospectively. The retrospective PA3 request must be submitted within the timeframe parameters stated within the MCD. For those services which do not currently have an MCD, the retrospective PA3 should be submitted within 14 calendar days of the start date of services.

Technical Guidance

To maintain adherence to the PA3 request retrospective timeframe requirements, the CCEs and NPN must manage their members’ care through efficient and effective case management services.

Compliant PA3 Request Submissions When a prospective or retrospective PA3 request is submitted within the appropriate timeframe, NIOSH will process the request to determine medical necessity and to render a decision.

Non-Compliant PA3 Request Submission Requirements When a retrospective PA3 request is being submitted outside of the appropriate timeframe, the CCE/NPN Clinical Director must include all documentation of justification and rationale for the non-compliant retrospective submission, including a timeline of events preceding the date of the PA request.

The timeline shall include, but is not limited to, specific dates the CCE/NPN was made aware of the services performed, steps taken to obtain the required information, provider outreach, payments that may have been made by other payers (i.e., member’s other insurance), and any other issues that affected the delay in submission.

Non-Compliant PA3 Request Submissions with Sufficient Justification Upon receipt, NIOSH will review the non-compliant retrospective request for potential extenuating circumstances and sufficient justification. A decision will be made on a case-by-case basis. If the retrospective submission is justified, the NIOSH will process the request to determine medical necessity and to render a decision.

Non-Compliant PA3 Request Submissions without Sufficient Justification If the CCE/NPN fails to meet their responsibility to submit the PA3 request within the timelines outlined in this guidance without sufficient justification, the Program will process the request and approve it if the service is medically necessary and meets all criteria (as outlined in the Administrative Manual or MCDs) are met. Additionally, the Program will track all unjustified non-compliant PA3 request submissions per CCE/NPN.

After this has occurred, the medical team will notify the Contracting Officer’s Representative (COR) of the need for a Corrective Action Plan (CAP) to improve case management care coordination. A CAP must be submitted to the Program to reflect the intention of the CCE to make improvements and prevent further incidence of non-satisfactory performance. This CAP must be submitted and reviewed by the Program and is subject to rejection and revision. The CAP becomes a part of the official contract file and may result in an impact to the contractor’s CPARS. Additionally, any costs incurred by a member or the Program due to the contractor’s failure to follow program guidance may result in the recoupment of those costs through reduction in invoice payments or claims.

Revision History Rev # Changes Made to Document Point of Contact Date

1 New Technical Guidance Document Hannah Dupont 03/29/2021

Revision History