Include key information in opioid requests to avoid processing delays

According to the U.S. surgeon general, more than 27 million people used illicit drugs or misused prescription drugs in 2015.¹ Among those who met diagnostic criteria for substance use disorder, 12.5 million people reported misuse of prescription opioid pain relievers.¹

In Michigan alone, 1,275 opioid overdoses occurred during 2015, accounting for 67 percent of all drug overdose deaths in the state. The number of opioid overdose deaths exceeded that of gun and traffic fatalities.² Opioid abuse continues to increase despite prevention efforts, such as state-run prescription drug monitoring programs and evidence-based prescribing guidelines.

The medical community can address this abuse by limiting prescriptions, yet opioids remain the mainstay of pain management. Restricting access may preclude patients from receiving necessary treatment. Insurers use utilization management, such as prior authorization, to help providers deliver effective therapy to patients while ensuring safe and appropriate use. However, opioid requests from providers often lack key information.

To prevent delays in processing these claims, submit all opioid requests with the following:

• Recent chart notes
• Diagnosis
• Documentation of trial and failure of alternatives
• Treatment plan

Chart notes are useful to verify dosing regimens and patient usage. Hospital chart notes are essential to review opioids prescribed during transition of care. If a patient continues therapy that was initiated in a hospital setting, hospital chart notes are required. This is especially important for cancer patients on opioid therapy or chemotherapy, because claims will be denied for both if chart notes aren’t included.

A diagnosis helps the insurer differentiate between opioids prescribed for pain and opioids prescribed for substance abuse disorder.

Documentation of a treatment plan, along with documentation of trial and failure of alternatives, ensures that the most up-to-date opioid prescribing guidelines are followed.

The opioid epidemic is a public health crisis that must be addressed through a collaborative effort at multiple levels of the health care system. Prior authorization programs reduce prescriptions for high-risk doses and decrease rates of opioid overdose.^3-5 With your help, we can continue to share in the responsibility to both curb prescription opioid misuse and connect more of our patients to safe and effective treatment.

For more information on the Blue Care Network utilization management criteria for opioids, please see our prior authorization and step therapy guidelines.

References

¹Mental, H. S. A. U. Office of the Surgeon General (US. (2016). Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health: 1-294.
²http://www.mlive.com/news/index.ssf/2017/06/michigan_opioid_heroin.html**
³Clark RE, Baxter JD, Barton BA, Aweh G, O’Connell E, Fisher WH. The impact of prior authorization on buprenorphine dose, relapse rates, and cost for Massachusetts Medicaid beneficiaries with opioid dependence. Health Serv Res 2014; 49(6):1964-79.
⁴Garcia MM, Angelini MC, Thomas T, Lenz K, Jeffrey P. Implementation of an opioid management initiative by a state Medicaid program. J Managed Care Spec Pharm 2014; 20(5):447-54.
⁵Faul M, Bohm M, Alexander C. Methadone Prescribing and Overdose and the Association with Medicaid Preferred Drug List Policies — United States, 2007-2014. MMWR Morb Mortal Wkly Rep 2017; 66(12):320-323.

**Blue Cross Blue Shield of Michigan doesn’t control this website or endorse its general content.