Continuity of Care (Revised)

REQUIREMENTS: - Effective immediately (policy revised May 27, 2026): Billing and prior authorization teams must apply the 90-day continuity of care window based on member eligibility start date, not enrollment date. - For all new or transitioning Medicaid Louisiana members: Verify eligibility start date is within previous 90 days before applying step therapy, prior authorization, or non-preferred edits to current medications. - CRITICAL: Do NOT override utilization management for the select list of medications (off-label use potential, high fraud/waste/abuse risk, or non-preferred generics with preferred AB-rated alternatives). These require standard review per SSA Title 19 requirements. - Prior authorization staff must document in claims system: (1) member stability on therapy, (2) compendia-supported diagnosis, (3) eligibility start date confirmation, (4) whether medication falls on the excepted medications list. - Deny claims for any off-label or off-evidence medication uses. Flag prescriptions for non-FDA-approved indications or those lacking peer-reviewed literature support for medical director review. - Update PA request forms and system workflows to capture eligibility start date and confirm medication stability (note: sample medications alone do NOT constitute stability). - Verify current medication list at time of claim—transition fills remain subject to appropriate review per state mandate. - Training: Educate billing, PA, and claims staff on the distinction between off-label (FDA-approved drug for non-approved use) vs. off-evidence (insufficient safety/efficacy data) to ensure correct denials. - Consequences of inaction: Claims inappropriately subject to step therapy or PA within the 90-day window may trigger member complaints and appeal denials; conversely, approving off-label/off-evidence uses violates federal Medicaid rules and may result in overpayments and compliance violations.