Massachusetts rolls out new prior authorization forms

Massachusetts commercial health insurance plans must accept new standard prior authorization forms for behavioral health services as early as Feb. 1 to comply with a mandate in the state’s 2012 health care reform law.

Providers fill out such forms to supply information needed by insured health plans to make decisions about covering requested services or procedures. Nearly all psychological and neuropsychological assessments require prior authorization.

Submitting forms is a time-consuming and often frustrating task for providers who may find themselves dealing with many different insurance companies, all with their own unique sets of questions.

Often, there are follow up questions.

Standard prior authorization forms were required by Chapter 224 of the Acts of 2012 titled “An Act Improving the Quality of Health Care and Reducing Costs Through Increased Transparency, Efficiency and Innovation.”

The forms were developed over a two-year long process led by the Mass Collaborative, an organization of more than 35 payers, providers, and trade associations dedicated to simplifying health care administrative processes.

Chapter 224 limited forms to no more than two pages in length. Insurers cannot require a clinician to send pages of medical records, tests or other documentation as part of the prior authorization process. The forms have sections relying on boxes that providers can check off, although they allow for an “other” option if none of the given criteria apply.

“Conceptually, this can be an extremely good thing for us,” said Massachusetts Psychological Association Director of Professional Affairs and Past-President Michael A. Goldberg, Ph.D., who participated in the Mass Collaborative group’s work on behavioral health services forms.

“Not only do we get a uniform form but we are also able to clean up a lot of what was asked and how it was asked,” Goldberg said.

Massachusetts is the second New England state to pursue standardizing prior authorization.

In 2014, Vermont required the state’s health insurers and Medicaid to start using a uniform medical prior authorization form for services for both physical and mental health conditions.

But the form is just one page and clinicians still have to send additional clinical notes and medical information to support their request. Insurers may still require providers to complete worksheets for some services, including psychological testing, to provide more information.

The Massachusetts Division of Insurance held two public meetings last June to solicit comments on three forms proposed by the Mass Collaborative before they were revised and resubmitted for approval.

Unveiled in a bulletin issued Nov. 3, 2015, were the Psychological and Neuropsychological Assessment Supplemental Form, Behavioral Health Disorders Level of Care Request Form (which includes a supplemental section for eating disorders), and Repetitive Transcranial Magnetic Stimulation Request Form.

The bulletin set a Feb. 1, 2016, deadline for paper forms providers may submit by mail, fax or as an attachment to an email. Then by May 1, all insured health plans must have amended their electronic or internet-based systems to collect prior authorization information.

“It was an interesting iterative process with a lot of back and forth and somewhat more collegial than you would expect, given that you have plans that are competitors with each other and then you have providers who don’t want to do prior auth to begin with,” said Mass Collaborative spokesperson Karen Granoff. She is senior director for managed care policy for the Massachusetts Hospital Association.

“Sometimes the plans would actually question each other. It wasn’t always providers saying, ‘What do you need to know this for?’ Sometimes one plan would have a piece of information that they felt was really necessary. None of the other plans had that, and they would say, ‘Can you live without that? Do you really need to have that?’”

Goldberg said the new forms eliminate problematic language and will help providers get authorizations for services more consistent with laws and regulations protecting patient access to the most appropriate care.

“I think this will increase efficiency for providers, but we also think that the content of the forms is much more appropriate and it is much more consistent with laws and regulations and, I believe, will result in fairer determinations by the health plans,” Goldberg said.

Goldberg cited Tufts Health Plan asking on its prior authorization form if patients are receiving special services at school, noting the answer could lead to a denial of benefits.

“We believe that that information has no bearing on the medical necessity criteria and insisted that it not be included,” Goldberg explained. “We found there were many questions asked that did not speak to the plan’s actual medical necessity criteria and prevented these questions from being included on the new form.”

Goldberg completed a literature review for ADHD-related testing and established criteria for when testing is not routine with specific questions prompting clinicians to report those situations. “I strongly believe that prompting for these data will greatly decrease inappropriate adverse determinations,” Goldberg said.

The Mass Collaborative has submitted its proposed prescription drug prior authorization form to the Division of Insurance and will submit a form for high tech imaging in the first quarter of the new year, Granoff said. Work on developing a medical-surgical procedure form will start sometime in 2016.