CMS-Required Outcome
The system enables the beneficiary to have timely access to medication if the system has the capability to perform prior authorization and provide a response by telephone or other telecommunication devices within 24 hours of a request and provides for the dispensing of at least 72-hour supply of a covered outpatient prescription drug in an emergency situation (unless excluded under the SSA ).
- Timely Access: Response to a Prior Authorization request provided within 24 hours.
- Timely Access: Emergency 72-hour fill requests reject rate - this can be the % of total POS claims not authorized with a 72-hour emergency fill.
- Section 1927(d)(5) of the SSA
How states write outcomes in this module
The Single Pharmacy Benefit Manager (SPBM) module will provide accurate and timely processing of pharmacy claims utilizing fully transparent pricing and payment methodologies as determined by the Ohio Department of Medicaid.
The Single Pharmacy Benefit Manager (SPBM) module will improve the accuracy and timeliness of the acquisitions and integration of pharmacy claims encounter data.
The Single Pharmacy Benefit Manager (SPBM) module will reduce the overall benefits and administrative costs of the Ohio Medicaid pharmacy program.