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Below is the HillCo client report from the April 23 Advisory Committee on Standardized PA Form for Medical Services meeting.

The committee held their first meeting to begin discussion on what the form should look like and the information that it should or should not include. Please see attached for the first draft form and below for committee comments.
 

  • SB 1216 passed in the 83rd Legislative session instructs the advisory committee to create a standardized form
    • Insurers must accept and use the form for any prior authorization of health care services beginning September 1, 2015
    • Insurers include commercial, Medicaid, CHIP, plans covering state employees, most school districts and the UT and A&M systems
    • Must be a paper form, to be faxed or mailed
  • Discussion about the form by the committee:
    • Basic design is pretty good, covers the basic points
    • Likes that section 6 allows for clinical information
    • Should there be instruction that section 6 should be limited to only what is being requested?
      • Avoid having to include other medical history
    • Want feedback from payors that this form is sufficient
    • ICD 10 has been delayed until October 2015 – does this form need to include ICD 9 AND 10?
    • Clinical staff prefer to do this online
    • Need to add a case manager contact and number that can be called
    • How is the form used in an urgent situation?
    • The form HAS to be online due to HIE and the EMR for the future
      • Law says it must be a paper form that is mailed or faxed
      • Member – providers are eliminating paper to protect privacy
      • Faxes don’t secure EHR and PHI
      • Want a form that can be typed into online with drop downs for insurer information to auto-populate and encryption
      • Asked for TDI to have a web page listing all the current insurer’s addresses and numbers if they cannot have it auto-populate
    • The onus should be on the insurer to return the form to the provider with a note of exactly what they require in order to approve a PA if they deny it
      • PA’s are not pended – they are either approved or denied based on TDI and HHSC rules
      • This is beyond the scope of the committee’s work
    • ICD codes are much more detailed so that should solve the specificity issue in approval of PAs – insurers should know exactly what the provider is asking for
    • Insurers want section 6 to give the provider flexibility to explain exactly what they are asking for
      • Do not want to be prescriptive

Tentative Decisions:

  • Reorder the sections:
  1. Patient information combined with carrier information
  2. Request Type (include medical reason for urgency)
  3. “Pertinent” Clinical Information
  4. Requested Service/Procedure
  5. Provider information
  6. Clinical Documentation
  • Remove the Service Type boxes completely under Section 2
  • Move “Start date” to under Requested Service/Procedure and Treatment Pattern
  • Include “site of service:”
  1. Inpatient
  2. Outpatient
  3. Doctor’s office
  4. Home
  5. LTC Facility
  6. Other
  • Debate over if they want to include a signature line for the requesting provider

 
TDI is going to take all these considerations and make a new form for the committee to critique. The committee members that work in smaller specialties (like therapy, DME) will send in their suggestions on how to make the form suit their needs specifically. The next meeting will be May 14th.
 

Attachments