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Incorrect Buprenorphine Prior Authorization Requirement

Thursday, January 2, 2020   (0 Comments)
Posted by: Janet Anderson
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December 24, 2019

 

HCA ALERT – Incorrect Buprenorphine Prior Authorization Requirement

 

Over the past few days, HCA’s Medicaid Program Operations and Integrity (MPOI) work unit has been working to respond to multiple provider and pharmacy reports that the Managed Care Organization (MCO) Coordinated Care of Washington (CCW) has been incorrectly requiring prior authorization (PA) for opioid use disorder (OUD) medications, specifically the combination buprenorphine-naloxone generic products and/or Suboxone. This incorrect PA requirement is known to have impacted dozens of clients and is a potentially widespread systems issue for CCW beneficiaries with OUD.

 

  • This systems issue will be getting fixed within CCW's internal corporate vendor- Envolve by January 1, 2020.
  • Until January 1, 2020, CCW will be directing their staff to manually override any PA barriers for these products.

    

In the interim, all providers/pharmacies are recommended to submit medication requests for combination products as usual.

 

For claims that are denied based on a PA request, providers and pharmacists can reach the CCW pharmacy vendor Envolve and its PA assistance hotline at:

 

  • 1-800-460-8988
  • Select option 2 for Medicaid
  • Select option 0 to speak with a live person
  • Explain the situation and that you know the PA is incorrect, and that Envolve is working on a systems fix by January 1, 2020, and ask for the PA to be removed for the CCW client. 
  • If the phone operator is not aware of this issue, please let them know you have received this documentation from HCA and would like to know how to send to Envolve a copy of this documentation from HCA to help substantiate your inquiry.
  • Provide the following information:
    • Patient name: __________________________
    • Apple health insurance number ________________________
    • Medication name __________________________

In the event these steps do not resolve the issue, please report the issue to HCA’s Managed Care mailbox: mcprograms@hca.wa.gov

 

Please note that your request is “URGENT”.

Please include the following information to help HCA staff triage your inquiry:

(1) Patient Name

(2) Apple health insurance number

(3) Medication name

(4) Managed Care Organization (e.g. Coordinated Care of Washington)

 

The HCA inbox staff can accept Protected Health Information (PHI) sent securely via any encryption service. If your agency lacks the ability to send in PHI securely via encryption, please note this barrier in your request. HCA staff will send you a response that will allow you to reply with PHI in a secure manner.

 

HCA staff will follow up with CCW and its vendor about these client cases to ensure that any PA barriers are removed.

 

Jessica K. Blose, CDP, LMHC, NCC, MAC, CCMHC

Washington State Opioid Treatment Authority 

Manager of Behavioral Health Clinical Support


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For persons with disabilities, this document is available in other formats. Please call 711 Washington Relay Service or email civil.rights@doh.wa.gov

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