To provide guidance for Medicaid Managed Care Plans (MMCPs) including Mainstream Medicaid Managed Care Plans (MMC), HIV Special Needs Plans (HIV SNP) and Health and Recovery Plans (HARP) and Managed Long Term Care Partial Capitation Plans (MLTCP), Medicaid Advantage Plans (MA), Medicaid Advantage Plus Plans (MAP) on New York State Department of Health´s (NYSDOH) accepted minimum standard data set required for Prior Authorization Requests (PA Requests) made by providers for services for Medicaid covered enrollees. This guidance applies to MMCPs and their contracted Utilization Review Agents (URA) where the URA is delegated for any part of the prior authorization process. This guidance is not applicable to PA Requests for Medicare covered services or to authorization requests for covered pharmacy benefits which utilize the standard NYS Medicaid Prior Authorization Request Form For Prescriptions. Note: MMCP implementation of this policy is not mandatory. However, if an MMCP chooses not to implement this policy, the MMCP must continue to accept and make a determination on all provider PA Requests received.

The Standardized Medicaid Managed Care Prior Authorization Data Set MRT II proposal creates a standard data set with minimum information needed for an MMCP/URA to accept and begin processing PA Requests from providers. The proposal seeks to reduce the amount of service authorization request denials and appeals solely due to a lack of information or insufficient information to begin processing a PA Request.

Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan/Health and Recovery Plan Model Contract (Model Contract), Managed Long Term Care Partial Capitation Model Contract, Medicaid Advantage Model Contract, and Medicaid Advantage Plus Model Contract.

MMCPs, and URAs where applicable, may implement policies and procedures that provide for the acceptance of provider PA Requests that contain all required minimum data set elements described in Section V of this guidance, also referred to as complete PA Requests, and for the rejection of provider PA Requests that do not contain all required minimum data set elements described in Section V of this guidance, also referred to as incomplete PA Requests. MMCP/URA policies and procedures for processing complete and incomplete provider PA Requests must comply with Section VI of this guidance.

MMCPs/URAs that do not implement policies and procedures for ascertaining the completeness of provider PA Requests in accordance with this guidance, must make a determination and issue notice for every provider PA Request received in accordance with applicable federal and state law and regulation and the applicable Model Contract.

All MMCPs/URAs must make a determination and issue notice for every PA Request made by an enrollee.

For the purposes of this policy, PA Request will have the same meaning as defined in Appendix F.1(1)(a)(i) of the Model Contract for MMC/HARP/HIV SNP, Appendix F.2(1)(a)(i) of the Medicaid Advantage Model Contract for MA, Appendix F.2(1)(a)(i) of the Medicaid Advantage Plus Model Contract for MAP, and as the term “Prior Authorization Review”, as defined in Appendix K(3) of the Managed Long Term Care Partial Capitation Model Contract for MLTCP.

This policy addresses only the minimum information needed for an MMCP/URA to accept and begin processing PA Requests from providers for services for Medicaid covered enrollees and does not amend any federal or state requirements related to the MMCP/URA processes and timeframes for making benefit coverage or medical necessity determinations; timeframes for issuing determination notices; other notice requirements related to the determination process; or the content requirements for such notices.

The minimum data set is information that is required to be submitted by the provider to the MMCP or URA, as applicable, with a PA Request in order for such request to be considered a complete request for the purpose of an MMCP/URA to accept and begin processing the request. The required minimum data set elements are as follows:

1. Enrollee Information
   1. Enrollee First and Last Name
   2. Enrollee Date of Birth
   3. Enrollee ID Number
      1. Plan ID number or CIN
2. Provider Information
   1. Prescribing/Ordering/Referring Provider Number
      1. Plan provider number, provider TIN, or provider NPI
   2. Prescribing/Ordering/Referring Provider First and Last Name
   3. Prescribing/Ordering/Referring Provider Telephone/Fax/Email and Address
   4. Servicing/Requesting Provider Number
      1. Plan provider number, provider TIN, or provider NPI
   5. Servicing/Requesting Provider First and Last Name
   6. Servicing/Requesting Provider Telephone/Fax/Email and Address
3. Clinical Information
   1. Order Description
      1. Description or procedure code of the requested service
   2. Diagnosis
      1. Description of the diagnosis/working diagnosis or the diagnosis/working diagnosis code
   Reminder: PHL §4905(7) prohibits a MMCP or their URA, where applicable, from routinely requiring providers to numerically code procedures and diagnoses.
4. Amount and Duration Information
   1. Order Date
   2. Quantity Requested
   3. Date of Service or Start and End Date for the Service
   4. Place of Service

1. Complete PA Requests
   1. A complete PA Request contains all required minimum data set elements described in Section V of this policy.
   2. Upon implementation of procedures for ascertaining completeness of provider PA Requests, the MMCP/URA shall accept all complete PA Requests. Acceptance means that the MMCP/URA has received all required minimum data set elements to begin the service authorization review process.
      1. The acceptance of PA Request is not a service authorization determination as defined in Appendix F.1(1)(b) of the Model Contract for MMC/HARP/HIV SNP, Appendix F.2(1)(b) of the Medicaid Advantage Model Contract for MA, Appendix F.2(1)(b) of the Medicaid Advantage Plus Model Contract for MAP, or as the term is used in Appendix K(3) of the Managed Long Term Care Partial Capitation Model Contract for MLTCP.
      2. The acceptance of a PA Request does not preclude the MMCP, or their URA, from requesting additional information from the provider, as needed, in order to make a determination on the service authorization request.
   3. In all cases the timeframe to make a service authorization determination begins at the receipt of the PA Request
      1. The timeframe to make a service authorization determination is not extended by any amount of time that the plan takes to ascertain that the request is complete.
      2. Reminder: The MMCP/URA, must comply with the service authorization review and noticing timeframes required by 42 CFR 438; applicable State statute and regulations; and the applicable Model Contract.
2. Incomplete PA Requests
   1. An incomplete PA Request is missing at least one minimum data set element described in Section V of this policy.
   2. Upon implementation of procedures for ascertaining completeness of provider PA Requests, the MMCP/URA shall reject all incomplete PA Requests.
      1. The rejection of an incomplete PA Request is not a service authorization determination as defined in Appendix F.1(1)(b) of the Model Contract for MMC/HARP/HIV SNP, Appendix F.2(1)(b) of the Medicaid Advantage Model Contract for MA, Appendix F.2(1)(b) of the Medicaid Advantage Plus Model Contract for MAP, or as the term is used in Appendix K(3) of the Managed Long Term Care Partial Capitation Model Contract for MLTCP.
   3. The MMCP/URA must notify the provider of an incomplete PA Request. Notice of an incomplete PA Request must:
      1. Be made to the provider immediately (within 12 hours of receipt of the PA Request), and;
      2. Identify the required data element(s) that are missing from the PA Request, and;
      3. Be transmitted in a manner and form agreed upon by the parties where the provider is contracted, or if no such agreement exists, be transmitted by the same method by which the PA Request was received.

1. An MMCP must notify the Department´s Utilization Review Unit if it chooses to implement or discontinue use of this Policy for any PA Requests it or its URA processes, at URAgent@health.ny.gov.
2. An MMCP must notify its network providers prior to implementing this policy in accordance with the notification requirements in the MMCP´s Provider Manual.
3. The Department will monitor the implementation of, and adherence to, this policy. MMCPs and their URAs will comply with Department direction, including modifying procedures and/or discontinuation of use.

Table 1 - Prior Authorization Minimum Data Set Policy Process