New Prior Authorization Form

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December 1, 2014

PROVIDER ALERT
To: Health Plan of San Joaquin (HPSJ) Physicians, Providers, and Pharmacies
From: Health Plan of San Joaquin Pharmacy Department
Subject: New Prior Authorization Form Required effective 1/1/2015
Products: All

Senate Bill (SB) 866 will become effective for DMHC regulated Health Plans (including HPSJ) on January 1st, 2015. This law requires a standardized prior authorization form be utilized across all Health Plans and other Risk Bearing Organizations. The form developed for use statewide is referred to as Form 61-211.

Key initiatives from SB 866 include:
  • Effective 1/1/15, only Form 61-211 may be used by plans and providers.
  • Requirement that the form be available on the organization website.
  • The updated PA form must be accepted through any reasonable means of transmission.
  • Only the minimum amount of information required for approval/disapproval may be requested.
  • The provider must be notified of the determination within two (2) business days of receipt of the request.
  • Disapproved requests must state clearly and accurately the specific reasons for the disapproval.
Submitting Prior Authorization Requests:
  1. Access the required PA form (form 61-211) at hpsj4.wpengine.com in the Provider section, or click here: Formulary Prior-Authorization Form
  2. Complete all fields as required so that HPSJ can process the request appropriately.
  3. Attach all relevant clinical information to support prior authorization review.
  4. Fax the request (and supporting documentation) to (209) 942-6302.
Tips for submitting successful prior authorization requests:
  • Fill out all fields on the PA form.
  • Submit supporting clinic notes, treatment plan, and lab values.
  • Use formulary alternatives (available using the Formulary Lookup Tool at hpsj4.wpengine.com) before requesting prior authorization. Give an adequate trial of formulary alternatives (including dose and duration) before concluding treatment failure.
  • For other medications tried, submit dates of therapy and results from those trials (it is also helpful to submit clinic notes documenting use of alternative agents).

Effective January 1st, 2015, HPSJ will ONLY accept the state mandated prior authorization form. Prior Auth requests using old PA forms will be rejected and must be resubmitted on the correct form.

The process for review and approval of authorization requests and requests submitted prior to 1/1/2015 are unaffected by this law.

Thank you in advance for your cooperation with this new state mandated requirement. If you have any questions, please call Provider Services Department at (209) 942-6340.

 

Posted on December 4th, 2014 and last modified on July 27th, 2015.

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