Prior Authorizations

Documents

• Prior Authorization Process
• Prior Authorization Process – Private Duty Nursing
• Speech Therapy Prior Authorization Resources
• PT/OT Prior Authorization Requirements
• 2024 Change Log 

Timelines

Prior Authorization Timelines 

Request for Authorization Services 

• STAR/STAR Kids – Within three (3) business days from the receipt of a request
• STAR/STAR Kids Members under the age of 21 – For a request for a UM determination that is lacking information, refer to the STAR <21 Lack of Information process
• CHIP – Within two (2) business days from the receipt of a request that results in an approval and three (3) business days for a denial

Concurrent Hospitalization Decisions 
Within 1 business day

Post-Hospitalization or Life-Threatening Conditions 

• Community First makes a medical necessity determination for life-threatening conditions or post-stabilization of care within one (1) hour from the receipt of the request.
• Authorization is not required for Emergency Care. “Emergency care” means health care services provided in a hospital emergency facility or comparable facility to evaluate and stabilize medical conditions of a recent onset and severity, including severe pain, that would lead a prudent layperson possessing an average knowledge of medicine and health to believe that the Member’s condition, sickness, or injury is of such a nature that failure to get immediate medical care could:
  • place the Member’s health in serious jeopardy;
  • result in serious impairment to bodily functions;
  • result in serious dysfunction of a bodily organ or part;
  • result in serious disfigurement; or
  • for a pregnant woman, result in serious jeopardy to the health of the fetus.

Pharmacy Prior Authorization Timelines 

• For Medicaid and CHIP – Immediately, if the prescriber’s office calls Navitus Health Solutions at 1-877-908-6023
• For all other Medicaid prior authorization requests – Navitus notifies the prescriber’s office no later than 24 hours after receipt
• If Navitus cannot provide a response to the pharmacy prior authorization request for Medicaid within 24 hours after receipt or the prescriber is not available to make a prior authorization request because it is after the prescriber’s office hours and the dispensing pharmacist determines it is an emergency situation, Community First and Navitus allows the pharmacy to dispense a 72-hour supply emergency supply at the discretion of the dispensing pharmacist

Notification Process for Incomplete Prior Authorization Requests

Incomplete or Insufficient Documentation Provided – effective 4/1/2021

•  Community First will no longer utilize the 16-hour or 7-day letter for those requests dated 04/01/2021 and moving forward in which additional clinical information is needed.
• Community First will instead issue a 3 Business Day letter to providers for outpatient requests in which additional clinical information is necessary to process the request.
• The 3 Business Day letter includes language for an opportunity to contact the Peer-to-Peer line at 210-358-6020 should the provider wish to schedule a discussion with a Medical Director.
• If the provider contacts the Peer-to-Peer line within the 3 Business Day timeframe to request a peer-to-peer discussion, an appointment will be scheduled prior to issuing a determination.
• No additional peer-to-peer letter will be sent.

The Process for Incomplete or Insufficient Documentation Goes as Follows: 

•  A letter is sent within 3 business days for the prior authorization request. The letter indicates the missing information needed and the timeframe by which to return the information (3 business days).
• If the information is not provided by the end of the 3rd business day after the letter is sent, and the request will result in an adverse benefit determination, the request is referred to a Community First medical director for review. This referral must occur no later than 7 business days after the original prior authorization Receive Date.
• Within 3 Business Days of the referral for medical director review, but no later than the 10th Business Day after the prior auth Receive Date, Community First must make a final decision on the prior authorization request.
• A peer-to-peer consultation can occur at any time during the prior auth request process after a medical director review. Community First must offer an opportunity for a peer-to-peer consultation to the requesting physician no less than one Business Day before an Adverse Benefit Determination is issued.

Note: For all lines of business, a peer-to-peer letter is sent to the requesting provider for those outpatient requests in which all the necessary information was provided but medical necessity could not be established, and the Community First Medical Director has requested a peer-to-peer offering before making a final decision.

Member Assistance 

If you are a Member and have questions about prior authorization, please call Member Services at 1-800-434-2347, Monday through Friday, 8 a.m. to 5 p.m. We are happy to help.