Health Information Technology   Preauthorization  

Electronic Preauthorization

Overview

Preauthorization is a process used by some health insurance companies that requires approval of certain health care services before being rendered by a health care provider. Preauthorization aims to ensure patients are receiving the most cost-effective and appropriate treatment; for example, certain prescription medications may be required for reasons such as the availability of low-cost generic alternatives, age restrictions, or prescribing higher than normal dosages. Historically, preauthorization has been a manual process, relying heavily on paper forms, faxes, and phone calls.  Electronic preauthorization provides an efficient means to submit, process, and track preauthorization requests using online preauthorization systems.    

Advancing Electronic Preauthorization in Maryland

Md. Code Ann., Health-General Article § 19-108.2, (law) enacted in May 2012, established three benchmarks, which aim to create administrative efficiencies in the preauthorization process by eliminating paper-based processes and enabling the electronic submission of preauthorization requests. The law required MHCC to work with State-regulated insurers, nonprofit health service plans, health maintenance organizations and pharmacy benefits managers (PBMs) (collectively “payors”) in implementing the benchmarks. In the 2014 session of the General Assembly, the law was amended adding a fourth benchmark.

Benchmark 1 - Provide online access to a listing of medical services and pharmaceuticals requiring preauthorization and the key criteria for making a determination

Benchmark 2 - Establish an online system to receive preauthorization requests electronically and assign a unique identification number to each request for tracking purposes.

Benchmark 3 - Process all electronic preauthorization requests within established timeframes – for pharmaceuticals, in real-time or within one business day upon receiving all pertinent information; and for medical services, within two business days upon receiving all pertinent information.

Benchmark 4 - Establish an electronic process to allow health care providers to override a step therapy or fail-first protocol when submitting an electronic pharmaceutical preauthorization request.

Progress

The law requires MHCC to report annually to the Governor and General Assembly through 2016. The MHCC has submitted the following legislative reports:.

Payors' & PBMs' Online Portals

Included below are links to payors’ and PBM’s online listing of medical services and pharmaceuticals requiring preauthorization and the key criteria for making a determination as well links to their online preauthorization systems.

Payors

1.   Aetna
          List of Services:

Online Portal

2.   CareFirst BlueCross BlueShield
          List of Services: 

Online Portal

  • Medical and Pharmacy
    *CareFirst providers should login to the online portal on the right menu; from there, they will be able to submit medical and pharmacy preauthorization requests  

3.   Cigna Healthcare Mid-Atlantic Region
         List of Services: 

Online Portal: 

4.   Coventry Health Care of Delaware
         List of Services: 

Online Portal: 

5.  Evergreen Health
         List of Services:

Online Portal:

6.   UnitedHealthcare
         List of Services: 

Online Portal: 

PBMs

  1. CVS Caremark  
  2. Express Scripts  
  3. OptumRX  

Benchmark Waiver Requests

The law gave MHCC authority to adopt regulations to establish a process by which a payor may be waived from attaining one or more of the benchmarks. COMAR 10.25.17.05 details the waiver process. All initial waiver requests or requests to renew a waiver should be submitted to Justine Springer at justine.springer@maryland.gov 

Additional Information

Electronic Preauthorization Infographic

This infographic provides a visual representation of the challenges with the traditional preauthorization process, the benefits of electronic preauthorization, and how to get started using payors’ online portals.
 

Electronic Preauthorization Flyer

This flyer summarizes the challenges with manual preauthorization processes involving paper forms, faxes, and phone calls. The benefits of electronic preauthorization are highlighted as well as information on payors’ online portals..
 

Items for Consideration in Implementing Electronic Preauthorization Phase 1

Items for Consideration in Implementing Electronic Preauthorization Phases 2 and 3
 
The MHCC issued the above guidance documents to assist payors and PBMs with implementing the phases of electronic preauthorization.
 

Recommendations for Implementing Electronic Prior Authorizations

In July 2011, the Joint Committee on Health Care Delivery and Financing of the Maryland General Assembly requested MHCC to develop recommendations for improving the paper-based preauthorization process in Maryland. The MHCC subsequently convened a workgroup, comprised of payors, PBMs, and health care providers. The workgroup’s recommendations are detailed within this report..
 
  

Last Updated: 11/1/2016