Report 2009-112 Recommendation 2 Responses

Report 2009-112: Department of Health Care Services: It Needs to Streamline Medi-Cal Treatment Authorizations and Respond to Authorization Requests Within Legal Time Limits (Release Date: May 2010)

Recommendation #2 To: Health Care Services, Department of

To ensure that Medi-Cal recipients receive timely access to prescribed drugs, Health Care Services should abolish its policy of responding to drug TARs by the end of the next business day and should instead ensure that prior-authorization requests to dispense drugs are processed within the legally mandated 24-hour period. Alternatively, it should seek formal authorization from CMS to deviate from the 24-hour requirement, and should seek a similar modification to state law. In addition, Health Care Services should begin recording the actual time it receives paper TARs so that it can begin to measure accurately its processing times.

Annual Follow-Up Agency Response From May 2016

CAASD had previously stated that a change as recommended would not be forthcoming until the new system being developed by CA-MMIS and Xerox was implemented. A change in the paper TAR process will likely implement prior to the implementation of the new system. A DHCS-sponsored bill, AB 1457, was recently signed into law by Governor Brown. This bill mandates the use of e-TAR for all fee-for-service treatment requests and eliminates the use of paper TARs. This mandate takes effect as of July 1, 2016. The implementation of the e-TAR mandate will render this recommendation moot. CAASD will develop a transition plan for providers who use paper TAR and related provider stakeholder groups to aid in the transition to e-TAR.

Next Business Day Adjudication of Drug TARs:

As indicated in 2013 status reports, it is not feasible for Health Care Services to process drug TARs within 24 hours of receipt because its offices are not staffed nor budgeted for 24-hour/seven-day-per-week operations. Emergency drug supplies are available to Medi-Cal beneficiaries as needed. In addition, Health Care Services has received few complaints from providers or beneficiaries regarding the timely processing of TARs. For these reasons, Health Care Services intends to continue its practice of adjudicating drug TARs by the next business day.

Health Care Services has not sought formal authorization from CMS to deviate from the 24-hour requirement because CMS is aware of Health Care Services' "next business day" practice and that emergency drug supplies are available to Medi-Cal beneficiaries as needed.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Annual Follow-Up Agency Response From December 2015

Next Business Day Adjudication of Drug TARs:

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Annual Follow-Up Agency Response From October 2014

CAASD had previously stated that a change as recommended would not be forthcoming until the new system being developed by CA-MMIS and Xerox was implemented. A change in the paper TAR process will likely implement prior to the implementation of the new system. A DHCS-sponsored bill, AB 1457, was recently signed into law by Governor Brown. This bill mandates the use of e-TAR for all fee-for-service treatment requests and eliminates the use of paper TARs. This mandate takes effect as of July 1, 2016. The implementation of the e-TAR mandate will render this recommendation moot. CAASD will develop a transition plan for providers who use paper TARs and related provider stakeholder groups to aid in the transition to e-TAR.

Next Business Day Adjudication of Drug TARs:

As indicated in the 2013 status update, it is not feasible for Health Care Service to process drug TARs within 24 hours of receipt because its offices are not staffed nor budgeted for 24-hour/seven-day-per-week operations. Emergency drug supplies are available to Medi-Cal beneficiaries as needed. In addition, Health Care Services has received few complaints from providers or beneficiaries regarding the timely processing of drug TARs. For these reasons, Health Care Services intends to continue its practice of adjudicating drug TARs by the next business day. Health Care Services has not sought formal authorization from CMS to deviate from the 24-hour requirement because CMS is aware of Health Care Services' "next business day" practice and that the emergency drug supplies are available to Medi-Cal beneficiaries as needed.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

Annual Follow-Up Agency Response From October 2013

Recording time of paper TAR receipt:

The actual time of paper TAR receipt will begin being recorded when Xerox, the CA-MMIS contractor, develops and implements the new TAR submission and adjudication system. The implementation of new TAR system is projected to begin early 2015. As in previous status update, modifying the current system would be costly and time intensive and not a prudent use of limited resources.

Next Business Day Adjudication of Drug TARs:

As indicated in previous status updates, it is not feasible for Health Care Service to process drug TARs within 24 hours of receipt because its offices are not staffed nor budgeted for 24-hour/seven-day-per-week operations. Emergency drug supplies are available to Medi-Cal beneficiaries as needed. In addition, Health Care Services has received few complaints from providers or beneficiaries regarding the timely processing of drug TARs. For these reasons, Health Care Services intends to continue its practice of adjudicating drug TARs by the next business day. Health Care Services has not sought formal authorization from CMS to deviate from the 24-hour requirement because CMS is aware of Health Care Services' "next business day" practice and that the emergency drug supplies are available to Medi-Cal beneficiaries as needed.

Estimated Completion Date: not available

California State Auditor's Assessment of Annual Follow-Up Status: Not Fully Implemented

Annual Follow-Up Agency Response From October 2012

The recommendation has two parts. The first is to abolish the policy of adjudicating drug TARs by the next business day and instead ensure prior authorization requests to dispense drugs are processed within the mandated 24-hour period. As an alternative, Health Care Services should seek formal authorization from the Centers for Medicare and Medicaid Services (CMS) to use the next business day timeframe and should modify existing state law accordingly. The second is to begin recording the time that Health Care Services receives paper TARs. As indicated in the previous update, Health Care Services will implement the second component, but not the first.

Record Time of Paper TAR Receipt

Health Care Services will begin to record the time of paper TAR receipt when Xerox, the new CA-MMIS contractor, develops and implements the new TAR submission and adjudication system. As noted in previous status reports, the current system does not have the capacity to record the time of TAR receipt, and it would be costly and time intensive to make the changes that would enable it to do so.

Next Business Day Adjudication of Drug TARs

As indicated in prior status reports, it is not feasible for Health Care Services to process drug TARs within 24 hours of receipt because its offices are not staffed or budgeted for 24-hour/seven-day-per-week operations. Emergency drug supplies are available to Medi-Cal beneficiaries as needed and do not require prior authorization. Health Care Services has received few complaints from providers and beneficiaries regarding the timely processing of drug TARs.

Health Care Services has not sought formal authorization from CMS to deviate from the 24-hour requirement. CMS is aware of Health Care Services' “next business day” practice and the availability of emergency drug supplies for Medi-Cal beneficiaries.

California State Auditor's Assessment of Annual Follow-Up Status: Will Not Implement

All Recommendations in 2009-112

Agency responses received after June 2013 are posted verbatim.