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Prior Authorizations, Tools, and Clinical Coverage Guidelines

last modified 12/08/2017 - 11:43 AM
Contributors: Keri Andersen

DVHA staff utilizes clinical criteria for making Utilization Review (UR) decisions that are objective and based on sound medical evidence. Approved criteria include the following:

  • Change HealthCare InterQual® Guidelines; 
  • DVHA Clinical Guidelines; 
  • Vermont State Medicaid Rules; 
  • Hayes and Cochrane New Technology Assessments; and   
  • Other Nationally Recognized Evidence Based Criteria. 

Change Healthcare InterQual® Guidelines are available to providers on the Vermont Medicaid secure provider web portal at https://www.vtmedicaid.com/secure/logon.do. After log-in, look for the link Change Healthcare Smart Sheets on the left window. InterQual® Guidelines are updated annually.

 

THERAPY GUIDELINES

 

FOR THE FORMS BELOW GO TO: http://dvha.vermont.gov/for-providers/forms-1

  • Therapy Extension Form, PTOTST, Pediatric Services (does not include home health agencies)
  • Therapy Extension Form, PTOTST, Adult Services(does  not include home health agencies)
  • Therapy Extension Form, PTOTST, Adult and Pediatric Services (home health agencies only)

PROCEDURE GUIDELINES

J CODE Forms: Pharmacy Prior Authorization Request Forms and Order Forms 

Imaging

 

 

 

 

 

 

INTENSIVE SOCIAL SUPPORT SERVICES
 

LABORATORY AND RADIOLOGY GUIDELINES

GENETIC TESTS

Genetic Test Forms

Criteria 

OUT OF STATE

http://dvha.vermont.gov/for-providers/forms-1
  • Out-of-State Elective Office Visit Request -PRINT AND WRITE IN FORM 
  • Out of State Elective Pre-Admission Request Form
  • Out of State Urgent and Emergent Admission Form 

MISCELLANEOUS

 Concurrent Review


Children’s Psychiatric Inpatient

 

Substance Abuse Treatment

                          *                                                          DURABLE MEDICAL EQUIPMENT                                            *

Durable Medical Equipment (DME) Acquisition Process (08/14/14)