MedicaidPrior AuthMedium impact
MAB2021110205
Pennsylvania Medicaid (DHS)·PA · Gastroenterology, Infectious Disease, Family Medicine +1 more·Provider Bulletin
Effective date
Jan 3, 2022
We identified it
Jun 20, 2026
Summary
Pennsylvania Medicaid has updated prior authorization guidelines for antibiotics, GI and related agents, effective January 3, 2022. Key changes include removal of specific Xifaxan guidelines, addition of Dificid criteria for C. diff infections, and revised requirements for IBS-D treatments requiring gastroenterologist consultation and low FODMAP diet failure.
Action Required
By January 3, 2022: Billing team must update prior authorization procedures for Pennsylvania Medicaid patients receiving antibiotics and GI medications. Ensure documentation includes: gastroenterologist consultation for IBS-D treatments, low FODMAP diet trial failure, high-risk factors for Dificid (fidaxomicin) approvals, and specialist consultation requirements for Zinplava. Update prior auth request templates to capture new clinical criteria. Claims may be denied without proper documentation of medical necessity.