By the Division of Insurance



Bulletin 2016-08

 

TO:                  Commercial Health Insurers; Blue Cross Blue Shield of Massachusetts, Inc.; and Health Maintenance Organizations Offering or Renewing Insured Health Products in the Massachusetts

FROM:            Daniel R. Judson, Commissioner of Insurance

DATE:            August 9, 2016

RE:                  Using Standard Prior Authorization Forms when Reviewing Requests for Medication and for Imaging Services

                                                                                                                                                           

The Division of Insurance (“Division”) issues this bulletin to inform insured health carriers (“Carriers”) about the use of standard prior authorization forms when reviewing requests for medication and for imaging services.  Pursuant to M.G.L. c. 176O, §25(c), the Division is mandated to implement health services prior authorization forms. 

The Massachusetts Collaborative, composed of representatives from insurance carriers, provider groups and associations, developed and submitted a series of standard prior authorization forms for use in reviewing requests for medication and for imaging services.  Based on the work of the members of the Collaborative, the group developed the following forms:

  1. Massachusetts Standard Form for Medication Prior Authorization Request pdf format of 2016-08-form1-medication.pdf
  2. Cardiac Imaging Prior Authorization Form to be used with Myocardial Perfusion Imaging (MPI); Stress Echocardiogram; Multiple Gated Acquisition Scan (MUGA); Transthoracic Echocardiogram (TTE); Transesophageal Echocardiogram (TEE) pdf format of 2016-08-form2-cardiac.pdf
  3. PET – PET CT Prior Authorization Form pdf format of 2016-08-form3-petct.pdf
  4. CT/CTA/MRI/MRA Prior Authorization Form pdf format of 2016-08-form4-ctmri.pdf

The Division held informational sessions on April 11 and April 28, 2016 to hear all thoughts about potential changes.  In response to comments provided during the information sessions,  the Massachusetts Collaborative submitted amended forms to the Division on June 10, 2016.  The amended forms, as included in the Appendix to this bulletin, are approved by the Division as the standard prior authorization forms for medication and imaging services under insured health plans.  Carriers may no longer require the use of any other paper form other than the standard form, which it shall make available for use by all contracted providers.

By no later than 90 days after the issuance of the bulletin, the Division expects that insured health plans shall take all necessary steps to amend their utilization review systems to accept any standard prior authorization form for medication and imaging services that may be submitted by providers by mail, as an attachment to electronic mail, or by facsimile machine.  The applicable standard prior authorization form will serve as sufficient information upon which the insured health plan should make its decisions about the medical necessity and appropriateness of the requested service or procedure.   For providers who use existing forms for prior authorization, Carriers will continue to accept these forms until six months after the issuance of this bulletin.

Six months after the issuance of this bulletin, the Division expects that all insured health plans will amend any electronic or internet-based systems used to collect utilization review information, so that those systems will only ask questions as stated in the approved forms in a format and order substantially similar to the format of the approved format.  Carriers wishing to modify the format or order from the standard form are required to submit screenshots of all such forms for the Division’s review before their use in the market.  Data collected electronically by Carriers for prior authorizations should be identical to the data collected on these paper forms.

The Division is aware that Carriers and providers may be at differing degrees of readiness for implementing standard prior authorization forms.  Although many provider organizations may be ready to implement the new forms, it appears that other providers may not yet be prepared.  The Division is sending this guidance to remind all Carriers of their obligations under federal rules.  As the paper forms become available, the Division strongly encourages Carriers to consider taking steps to work with provider organizations to educate contracted and other providers about the use of uniform prior authorization forms for medication and imaging services.  Carriers are encouraged to work with contracted providers to use the standard forms within 90 days and electronic form by no later than six months after the issuance of this bulletin.

If you have any questions about this Bulletin, please contact Kevin Beagan at 617‑521‑7323 or Kevin.beagan@state.ma.us.