Express authorizations can be performed faster and more easily with the use of drug formularies. The recent release of the California Drug Formulary uses a very objective language suitable for fully- or partially-automated approval of requests.

For example, after entering a medication request in DataCare’s UR++ system, the system can easily determine if the request should be approved immediately or sent for formal UR. UR++ is a rules-based system and can take into consideration information such as: medication being prescribed within the first week of injury; affected body part; type of medication (opioid, antibiotic, analgesic, etc.); and the name of the medication or any included ingredient. Furthermore, the system is capable of determining equivalency of medications (those containing identical ingredients) and may determine any amount of a given medication that has been authorized (or even paid for) in the recent past; this information can be used in the automated rules as well.

Thus, once the RFA is in the system, all one has to do is to enter the medication or treatment requested and the system will generate and send the actual authorization, or, if indicated by the rules, automatically and immediately forward the RFA to formal UR. Does the request contain both approvable and questionable treatments? No problem–approve what you can immediately, and send the remainder for UR. It is that easy!

UR++ is a DataCare product that can be used independently or along with the Ahshay! claims system. It allows users to approve or refer requests for authorization quickly and efficiently, and leverage historical data about the associated claim where possible. UR++ and its workflows are highly configurable, allowing clients to implement the workflow that works best for them. The program can directly send approval, denial, and objection letters, and also facilitate seamless data transfer to external UROs using the Ahshay! system.

 

About the Author: