The process to request coverage of Synagis for a North Carolina Medicaid recipient has changed many times over the years. With each change, Medicaid hoped to improve on the appropriate identification of children meeting medical necessity criteria for Synagis prophylaxis according to clinical criteria and Early and Periodic, Screening, Diagnosis and Treatment (EPSDT) policy. The importance of keeping processes simple and efficient for the provider is an inherent consideration.
In early spring 2011, Medicaid, through a survey sent to pediatric practices across the state, collected information on how Synagis is managed within an office. Medicaid partnered with the Community Care of North Carolina to analyze the information. That collaboration was the springboard for development of an electronic prior approval method. From the survey responses, Medicaid ascertained encouraging application of the current Red Book guidance for prophylaxis would benefit key staff involved with Synagis. Provider comments revealed a need to improve the response time about which requests meet the criteria for coverage. Framing the current Red Book guidelines within an electronic system that provides real time feedback achieves a benchmark of providers and Medicaid.
Note: Session Law 2011-145 House Bill 200 supports submission of requests for prior authorizations electronically via a website. Click on RESOURCES for the link to the legislative language mandating electronic PA requests.
The electronic prior approval process has built in prompts to help the user ensure information essential for a Synagis request is provided. An automatic approval feature will allow providers to print instantly the notification to send to the Synagis distributor. Providers will be able to monitor the status of a pending request by simply logging onto the system. Frequent checks for status changes are recommended because the system will update real time. A timely response is needed when additional information about a case is requested. Failure to respond in a timely way will diminish the benefit of real time communication about a PA request.
First you must register to gain access to the website. This is done by going to the Registry tab. You will need to submit some basic information (name, contact information) for both yourself as the provider as well as the practice / hospital / healthcare organization with which you are affiliated.
Once your access request has been validated, you will be provided with a user ID and temporary password. You will need to go into the registry to update your password before you can begin entering information for specific patients.
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