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Prior Authorizations, Tools, and Clinical Coverage Guidelines

last modified 10/31/2018 - 03:13 PM
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 

ACO Prior Authorizations

 ACO prior authorization requirements were waived in 2018 for all ACO members and services. However, Medicaid's claims-processing system continues to look for a PA for certain services. See necessary documentation below for guidance. The below full list notes if Prior authorization is waived for ACO member, it will note if the short form is needed for Prior Authorization, If a Prior Authorization is needed  as well has notes if Prior Authorization is needed for certain diagnosis code. Services that need Prior Authorization should use the Forms found on this page. A temporary short form has been created until the system is modified for codes noted needing a short form

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

  • FOR THE FORM BELOW GO TO:
    • Program on hold

Children’s Psychiatric Inpatient

 

Substance Abuse Treatment

 

Metabolic Nutrition

                          *                                                          DURABLE MEDICAL EQUIPMENT                                            *

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