Clinical edits check a patient's Medicaid medical and drug claims histories to help determine whether the information on file indicates that the patient's medical condition matches the edit criteria for dispensing the requested drug without need of additional prior authorization. The edits are based on evidence-based clinical criteria and nationally recognized, peer-reviewed information.
Clinical edits, along with the Preferred Drug List (PDL), will help optimize the use of program funds while ensuring access to care through the therapeutically prudent use of pharmaceuticals.
HHSC will phase in new edits for medications for both Medicaid nursing home recipients and for the general Medicaid population over time, after HHSC receives feedback on proposed edits from the Drug Utilization Review (DUR) Board, the Texas Medical Association, and other stakeholders.
Resources
How the Clinical Edits Work
- With the clinical edits, prior authorization calls may be required for both preferred and non-preferred drugs (the prior authorization process is similar to the process already established for the the PDL).
- Prior authorizations will be handled both through SmartPA (an automated, point-of-sale system) and the Texas Prior Authorization Call Center. SmartPA will help minimize the need for prior authorization phone calls.
- HHSC will establish clinical criteria by which recipients will be able to receive certain products. The criteria may include age, diagnosis from medical history, or inferred diagnosis from prescription claims history.
- When a pharmacy submits a Medicaid claim for a product subject to a clinical edit, the SmartPA system will check the patient’s available medical and prescription drug claims histories to determine whether the information in the system shows that the patient's condition meets the established criteria.
- If the patient’s medical and claims histories demonstrate the criteria are met, the claim will be approved.
- If the patient's medical and claims histories do not meet the criteria, the pharmacy will receive a message indicating that the prescriber needs to call the Texas Prior Authorization Call Center at 1-877-PA-TEXAS.
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