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Timely Services and Prior Authorization for Medications

PDF Version of BQA 04-018 (PDF, 24 KB)

DATE: July 19, 2004 DSL-BQA-04-018

TO: Nursing Homes NH 08

FROM: Michael J. Steinhauer, Resident Care Review Section, Bureau of Quality Assurance

via: Criselda Ros-Dukler, Director, Bureau of Quality Assurance

Over the past few months, the State Medicaid program has implemented a requirement for the prior authorization of certain medications in order to decrease medication costs. This process usually designates one or more medications as the preferred medication for a condition and requires all others to be authorized for Medicaid payment before they are dispensed. The process of obtaining prior authorization is usually an automated process and requires information from the physician. That information is then used by the pharmacy to dispense the medication.

When dispensing medications that require prior authorization, some pharmacies may decide not to fill the prescription until the prior authorization is obtained. Nursing homes have expressed concerns that they are at risk of being cited for failing to provide timely services when the pharmacy delays sending the medication. This memo addresses those concerns.

Surveyors consider a residentís condition and the treatment that was ordered when they evaluate whether a resident received timely services. Failing to provide timely services may be cited if a resident can be harmed by not receiving a medication in a timely manner.

Some medications are needed sooner than others. For example, residents who are suffering pain cannot wait two or three days to receive their medication. However, residents who have had high cholesterol for quite some time may not necessarily need to immediately start a medication prescribed to address that condition.

The facility and the pharmacy should work together to decide if a specific medication is needed immediately or can be delayed. The facility may need to consult with the residentís physician as well. If the medication is needed immediately and the pharmacy cannot obtain prior authorization, the pharmacy may dispense a small emergency supply of medication that can be billed according to Medicaidís emergency services guidelines.

If you have further questions, please call Doug Englebert at 608-266-5388.

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