Prior Authorization Requirements Exemption Request (Page 2 of 2) in pdf

PRIOR AUTHORIZATION REQUIREMENTS EXEMPTION REQUEST FOR COMPUTED TOMOGRAPHY (CT)

Page 2 of 2

AND MAGNETIC RESONANCE (MR) IMAGING SERVICES

F-00787 (05/13)

SECTION II — REQUIREMENTS

The provider, provider group, or health system must meet the following requirements for approval of their decision support tool as an

appropriate alternative to current Department of Health Services’ PA requirements:

7. The provider or health system has fully implemented a decision support tool for use among its providers to order CT and MR

imaging services.

a. Identify the decision support tool in use.

b. Identify the date on which the decision support tool was fully implemented and functional.

8. The provider or health system has developed a quality improvement plan to address over- and under-utilization by providers. The

guidelines include interventions, timelines, and outcome measures. Detailed quality improvement plans should be submitted with

this application. The outcome measures should include, at a minimum:

a. Aggregate score for all providers, measuring consistency with system recommendations based on the reporting standards

described in more detail in Section III.

b. Subset scores, grouped by primary and specialty care.

c. Aggregate outcome measures identified in the quality improvement plan.

9. The health system agrees to report outcome measures to ForwardHealth for each full six-month interval (January 1 through June 30

and July 1 through December 31) by July 31 and January 31 of each year.

10. The health system agrees to identify and submit to ForwardHealth the names and NPIs of individual providers who will use the

decision support tool to order CT and MR imaging services.

11. The health system agrees to submit to ForwardHealth additions, deletions, and other updates as needed to the provider exemption

list to ensure current and accurate information. Large lists should be provided along with semi-annual outcome measure reporting.

SECTION III — SUPPORTING INFORMATION

Provide the following information in the space below each statement or as a separate attachment.

12. Describe the provider educational component(s) of the decision support tool, including any real-time access to radiologists when

requested by the ordering provider and/or feedback to providers who vary significantly from the recommendations of the decision

support tool.

13. Describe the internal processes to provide feedback to individual providers as needed regarding their use of and compliance with

the decision support tool.

14. Describe the calculation of the aggregate score for consistency with system recommendations to be submitted to ForwardHealth,

including the basic components of the score and qualifications to the score’s calculation, such as the exclusion of certain types of

orders.

SECTION IV — ATTESTATION

By signing below, the health system attests to satisfying all requirements defined in this form.

15. Name — Authorized Agent (Print)

16. Title — Authorized Agent

17. SIGNATURE — Authorized Agent

18. Date Signed

Prior Authorization Requirements Exemption Request Page 2