Hepatitis C Virus (HCV) Retrospective Review Process

REQUIREMENTS: - Effective immediately (December 3, 2021): Billing and clinical teams must ensure all HCV prior authorization requests submitted to MCOs include complete documentation per the clinical criteria in Attachment A, including: chronic HCV diagnosis with genotype/sub-genotype, HCV RNA quantitative (within 180 days for non-cirrhotic; within 90 days for cirrhotic patients), fibrosis test results, prior treatment history, HIV/HBV status with viral suppression data (within 6 months), and adherence assessment. - By first submission: Providers must reference the genotype-specific treatment tables (Treatment Naïve or Treatment Experienced by prior regimen type) to ensure prescribed HCV medications align with approved therapy duration and regimen by cirrhosis status (None/Compensated/Decompensated). - Before each HCV prior authorization submission: Confirm ribavirin-containing regimens include documented dual contraception plan for patients/partners of childbearing age throughout therapy plus 6 months post-treatment. - Ongoing: Coordinate with MCOs to understand their retroactive review findings; any MCO sanctions for non-compliance may affect payment for previously approved claims. Track all HCV approvals for audit purposes to demonstrate 100% compliance with clinical criteria. - Responsible parties: Providers (treatment plan development and documentation), Billing team (prior auth submissions with complete documentation), Pharmacy (verify medication selection matches criteria tables). - Consequence: MCO sanctions for <100% compliance with HCV Clinical Criteria; claim denials if documentation is incomplete or therapy selection deviates from approved protocols.