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 resident’s 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 resident’s 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 Medicaid’s emergency services
guidelines.
If you have further questions, please call Doug Englebert at
608-266-5388.
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