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common credentialing form, this is the first step in creating a common form for preauthorization. And we believe what we came up with is not overly onerous for physicians, but also provides a great deal of information to help third-party payers make their decisions.” The medical and health care ser-


“The fact that we have to use only one form and can get it done and move on to more important things makes our lives a lot easier.”


vices form, for example, contains six standardized fields asking physicians for information on:


• The patient’s health plan, • Whether the request is urgent, • The patient, • The physician or facility making the request,


• The services requested and related codes and diagnoses, and


• Clinical documentation. In fact, health plans may already


prepopulate their contact information on the forms posted on their websites. Because the prescription medica-


tion form covers compound drugs and some devices, that document is two pages, says Gary J. Sheppard, MD, an internist at Southwest Memorial Physician Associates in Houston, who serves on that workgroup. “But the most important thing is,


it’s going to be the same, whether it’s Aetna, Blue Cross, Humana, or Medic- aid,” he said. “The fact that we have to use only one form and can get it done and move on to more important things makes our lives a lot easier.” As part of the Texas Health and


Human Services Commission’s own administrative simplification overhaul, which includes streamlining Medicaid prior authorization, officials told Tex- as Medicine the agency coordinated with TDI to avoid any duplication of work. (See “Seeking Simplicity,” Au- gust 2014 Texas Medicine, pages 33–37, or www.texmed.org/SeekingSimplic ity.aspx.)


COLLABORATIVE EFFORT During the 2013 legislative debates, while generally on board with the idea


32 TEXAS MEDICINE March 2015


of standardization, health insurers ini- tially bristled at the possibility of con- densed forms over concerns that too little information could cause care delays if plans couldn’t ask additional questions at the outset. A complicated hip replacement, for example, may re- quire more information than a mole removal. But Dr. Levy says, “Once the uneas-


iness was overcome, there was a great collaborative effort by everybody to try to create a form that would work,” adding that health plans indicated it could help reduce some of their work burden, as well. Dr. Sheppard agrees the biggest


challenge was “figuring out how much to put on the form. Health plans al- ways want more information, but it’s not always readily available to us [physicians].” For example, insurers may ask for


patients’ five-year prescription his- tory, but they’ve only been under Dr. Sheppard’s care or with their current insurance plan for two years. Plans also typically ask for National Drug Code numbers for active and inactive ingredients in compound medications. “But we [doctors] don’t always


know. It might be available in some EMRs (electronic medical records). But not all physicians have that infor- mation and would have to look it up. And pharmacists chimed in to say, ‘We know that in the pharmacy. But that’s not something doctors are going to know,’” Dr. Sheppard said. The discus- sions were productive, he adds, “and really brought some reality to what [insurers] think they want and what can actually happen.” Health plan representatives did not


respond to Texas Medicine’s requests for comment. TDI Special Advisor for Policy De-


velopment Patricia Brewer clarified that the legislation and the new forms do not change insurers’ approval cri- teria or processes required to support the medical necessity of a particular procedure, for example. Nor can phy- sicians use the standardized forms to:


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