Making health care easier and more transparent with PA 60

Michigan Prior Authorization Reform / Public Act 60, set to go into effect on June 1, seeks to reduce wait times and streamline how we work with each other, making it easier for our members, your patients, to get the care they need when they need it.

As a plan accredited by the National Committee for Quality Assurance (NCQA) and adherent to NCQA’s Utilization Management standards, we’re excited to share how we already meet many of the new requirements and the work we’re doing to make it even easier for our providers and members to work with us.

PA 60 requirement	Priority Health status
Standardized electronic prior authorization request transaction process.	We meet this requirement with our current medical and pharmacy electronic prior authorization systems.
Clinical review criteria posted on website for members and providers.	We currently have our medical policies available online, and clinical criteria – such as InterQual – are available to providers through prism. Pharmacy clinical review criteria are currently available on our public website as well. We’re on track to give our members access to clinical criteria online by June 1.
Clinical criteria development and review requirements.	We meet this requirement with our current medical and pharmacy development and review processes for clinical criteria. This process is led by our Medical Advisory Committee, made up of community physicians.
List of benefits subject to prior authorization available on public website.	We meet this requirement for pharmacy as our formulary currently lists all scenarios when prior authorization is required. We’re on track to provide comprehensive information on all prior authorization requirements for medical services by June 1.
Advance notice of prior authorization changes.	We currently meet this NCQA requirement for both our medical and pharmacy notification processes.
Prior authorization request review and decision making by appropriate professionals.	We currently meet this NCQA requirement with our medical and pharmacy processes for review and decision-making, as denials are determined by a medical director, physician advisor or pharmacist.
Prior authorization denial notification to include reason for denial, related evidence-based criteria and right to appeal.	We currently meet this NCQA requirement with our medical and pharmacy denial notifications.
Shorter prior authorization turnaround times.	Our standard, non-urgent turnaround times will be set to 9 days effective June 1. Our urgent medical and pharmacy requests currently meet the 72-hour turnaround time.

We’re on track to meet all other legislative guidelines on or before June 1. We’ll share updates here in the Provider Manual, through our physician newsletter and Virtual Office Advisory (VOA) webinar when changes are available.