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Physician-Administered Drug (PADs) Prior Authorization (PA) Frequently Asked Questions (FAQs)

  1. Do all PADs require a prior authorization (PA)?
    1. No – only the Healthcare Common Procedure Coding System (HCPCS) and PADs listed in Appendix Y require a prior authorization
    2. Please refer to the Physician Administered Drugs web page
       
  2. What is the maximum length for a PAD PA?
    1. PA approval length may be up to a maximum of 1 year (365 days)
    2. The maximum PA approval length specific for each HCPCS requiring a PA can be found on Appendix Y
       
  3. Are retro PA requests (PARs) allowed for PADs?
    1. Retro requests are currently not allowed in the CO PAD program with few exceptions due to extenuating circumstances prior to May 1, 2022
       
  4. What are the normal operating hours for Acentra?
    1. Normal operating hours for PAD clinical review is Monday through Friday from 7:00 am to 5:00 pm MST
    2. After hours coverage will be available for PA review as appropriate
       
  5. How do I submit a PAR?
    1. PARs may be submitted via Acentra
    2. Additional helpful links:
      1. Video recordings, training manuals, user guides, etc. can be found on the ColoradoPAR Training webpage
      2. Provider Portal User Guide
      3. Provider Contacts
         
  6. What kind of supporting documentation is required for PAR submission?
    1. Supporting documentation may consist of:
      1. Chart notes confirming the patient’s diagnosis
      2. Dosage and history of treatment with requested medication
      3. History of prior medications which have been tried and failed
      4. Additional information which may be requested as needed
         
  7. What are the turnaround times (TAT) for a PAD PA determination to be made?
    1. From the time a completed request is received (a request is complete upon submission of all pertinent information)
      1. PAD Prospective Standard Request: 24 hours TAT
      2. PAD Urgent (Expedited) Request (must meet the urgent request standards): 4 hours TAT
      3. All requested information submitted on the portal as a response to a request for more information (RFI): 24 hours TAT
         
  8. What constitutes an Urgent (Expedited) Request?
    1. An expedited PAD PAR is that which is urgent (expedited) because a delay in treatment could:
      1. Jeopardize the life or limb of the member OR
      2. Jeopardize the member’s ability to attain, regain, and/or maintain maximum function
         
  9. Remicade is listed as requiring a PA – what about biosimilar drugs?
    1. Only the HCPCS and PADs listed on Appendix Y require a PA
       
  10. What are the next steps after a PAR is denied?
    1. Following a PAR denial, there are three potential options which may be pursued:
      1. Reconsideration Request
        1. The provider may request a reconsideration to Acentra within ten (10) days of the initial denial
        2. Additional information and documentation must be submitted for reconsideration of the PAR
      2. Peer to Peer (P2P) Request
        1. The provider may request a Peer-to-Peer review within five (5) days from the date of the medical necessity adverse determination.
        2. A P2P cannot be performed on a technical or administrative denial.
      3. Formal Appeal
        1. Additional information will be provided in denial letters
        2. Process must be pursued by the member
      4. It is strongly encouraged that a provider exhaust both reconsideration and P2P options prior to a member pursuing a formal appeal.
         
  11. How often will Appendix Y be updated?
    1. Appendix Y may be updated on an as needed basis and usually in conjunction with determinations made during the review of PA criteria at quarterly Drug Utilization Review Board (DUR) meetings.
      1. Information related to the DUR Board, including meeting agendas can be found on the Drug Utilization Review Board web page.