The passage of House Bill 517 (HB517), the budget trailer bill, places new responsibilities on the Department to oversee the Medicaid managed care organizations’ (MCOs) prior authorization (PA) requirements for behavioral health drugs. The bill amends RSA 126-A:5,XIX by requiring the Commissioner to develop a universal online PA form for drugs used to treat mental illness by July 15, 2017 and requires community mental health centers (CMHC) and managed care organizations to use the universal PA form by September 1, 2017.

See FINAL NH Medicaid MCO Behavioral Health Drug PA Form

The bill also places stringent turnaround times on both prior authorization decisions and requested peer-to-peer reviews following denials of prior authorization requests. To quote: “A reasonably completed prior authorization request submitted using the online form shall be approved or denied by the close of the next business day.”

See FINAL Uniform PA Rx Approach Document

“Failure to meet this time frame shall be deemed automatic approval. If the prior authorization is denied, the prescribing provider may request a peer‐to‐peer review with a licensed psychiatric specialist with prescribing privileges, with the MCO, by the close of the next business day.”

“Failure by the managed care organization to provide such review by the close of the next business day shall be deemed an automatic approval unless the prescribing provider fails to participate in the peer‐to‐peer review within that time period.”

Prior authorization for drugs prescribed by community mental health centers for treatment of severe mental illness shall be suspended if the deadlines are not met, or if the Commissioner determines there is a pattern of missed deadlines for peer-to-peer reviews following denials, or if at any time the Commissioner determines such suspension is necessary to promote the behavioral health and well‐being of New Hampshire's citizens being served under Medicaid managed care.

See FINAL Patient Rights CMHC PA Rx Implementation

The Commissioner is also required to monitor compliance with the law and report quarterly to the fiscal committee of the general court relative to adherence to all such requirements including the rate of denial. The Department will outline the reporting specifications necessary for the commissioner to effectively monitor compliance, as required above.

See FINAL BHDRUG01 Reporting Document

For further information, please contact:
Deb Scheetz, Director
Integrated Healthcare Reform
(603) 271-9459
deborah.scheetz@dhhs.nh.gov

BHDRUG01 Uniform Prior Authorization Reporting
(documents are in Adobe PDF Format )

NH Healthy Families			Well Sense
2018	2017		2018	2017
February 2018 *	12/24-12/30/2017		February 2018 *	12/24-12/30/2017
02/11-02/17/2018	12/17-12/23/2017		02/11-02/17/2018	12/17-12/23/2017
02/04-02/10/2018	12/10-12/16/2017		02/04-02/10/2018	12/10-12/16/2017
01/28-02/03/2018	12/03-12/09/2017		01/28-02/03/2018	12/03-12/09/2017
01/21-01/27/2018	11/26-12/02/2017		01/21-01/27/2018	11/26-12/02/2017
01/14-01/20/2018	11/19-11/25/2017		01/14-01/20/2018	11/19-11/25/2017
01/07-01/13/2018	11/12-11/18/2017		01/07-01/13/2018	11/12-11/18/2017
12/31/2017-01/06/2018	11/05-11/11/2017		12/31/2017-01/06/2018	11/05-11/11/2017
	10/29-11/04/2017			10/29-11/04/2017
	10/22-10/28/2017			10/22-10/28/2017
	10/15-10/21/2017			10/15-10/21/2017
	10/08-10/14/2017			10/08-10/14/2017
	10/01-10/07/2017			10/01-10/07/2017
	09/24-09/30/2017			09/24-09/30/2017
	09/17-09/23/2017			09/17-09/23/2017
	09/10-09/17/2017			09/10-09/16/2017
	09/03-09/10/2017			09/03-09/10/2017
* Reporting frequency change from weekly to monthly

Frequently Asked Questions

Additional Documentation

• FINAL Pediatric EPSDT Off Label Guidance
• FINAL COPY of NH Healthy Families Behavioral Medication List
• FINAL COPY of Well Sense Behavioral Medication List

MCO Authorized Representative Forms for Standard Appeals

• NH Healthy Families
• Well Sense Health Plan (General Form)
• Well Sense Health Plan (Appeal Specific)

Adobe Acrobat Reader format. You can download a free reader from Adobe.

Microsoft Excel format. You can download a free reader from Microsoft.