MedicaidPrior AuthMedium impact
MAB2023111301
Pennsylvania Medicaid (DHS)·PA · Gastroenterology, Infectious Disease, Family Medicine +1 more·Provider Bulletin
Effective date
Jan 8, 2024
We identified it
Jun 20, 2026
Summary
Pennsylvania Medical Assistance (Medicaid) updated prior authorization requirements for antibiotics, GI medications, and related agents, adding new guidelines for small intestinal bacterial overgrowth (SIBO) diagnosis and updating existing criteria for various conditions including C. diff infections and IBS-D.
Action Required
By January 8, 2024: Billing team must update prior authorization workflows for Pennsylvania Medicaid patients receiving antibiotics and GI medications. Ensure providers document that IBS-D and SIBO treatments are prescribed by or in consultation with gastroenterologists. Update encounter forms to capture required clinical criteria including patient age, therapeutic failures, contraindications, and specific risk factors for C. diff infections. Review updated handbook pages for complete medical necessity guidelines.