(Spravato MA Workflow - Pre Administration (Prior Authorization, ordering, and Scheduling)

(Spravato MA Workflow - Pre Administration (Prior Authorization, ordering, and Scheduling)

Spravato MA Workflow - Pre Administration

 

Pre-requisites: 


     Pre Auths:  
  1. Autorization order must be submitted during the consultation appointment 
  1. Insurnace information and card must be updated and current (within the year) 
  1. Prior Authorization must be completed prior to scheduling an administration appointment 
  1. Adequate supporting documentation must be available before submitting an authorization 
  1. Spravato With Me Enrollment should be submitted at some point between the screening appointment or before scheduling the administration appointment to ensure patients understanding of their cost of service. 
  1. Obtain an ROI to request past medication History from pharmacy which provides past scripts and duration of trial. 

Medication order:  

  1. Authorization must be approved before ordering medication to ensure proper routing and forms in place 
Administration Scheduling 
  1. Authorization should be approved before scheduling an administration appointment 
  1. Benefits should have been reviewed before scheduling this appointment (Skip to bottom see Spravato with me & REMS) 
  1. REMs enrollment should have taken place before scheduling this appointment (Skip to bottom see Spravato with me & REMS) 
Prior Authorizations: 

A prior authorization request for Spravato Treatment will be automatically routed to the corresponding department Spravato bucket (eg ilwesttownspravato) 


Work the incoming order: 

Review all appropriate items on file 
  1. Is there active and eligible insurance with a current photo? 
  1. Is there a consultation note with appropriate documentation? 
  1. Is there a recent PHQ9 on file (with appropriate scoring)  
  1. Sometimes a MADRS is used in place of this 
  1. Has the patient tried and failed at least 3 antidepressants from 2 different classes (e.g. SNRI / SSRI) 
  1. Does the patient have Major Depressive Disorder and or Treatment Resistance Depression in their problems list.  

NOTE: if any of the above is missing connect with the provider to confirm clinical necessity and obtain any supporting information to be used on the prior authorization for approval before moving on to the next step 


Submit the Authorization:  

Identify the appropriate benefits manager 

      

Is there a pharmacy benefits manager on the insurance card?  

If yes – proceed with submitting through the pharmacy benefits manager first (See support auth info below)
  1.          If submitting via pharmacy benefits typically you can request both 84mg and 56mg on the same auth request (start with submitting 84mg and ensure to notate 56mg as the induction dose as well) 
  1. QTY & Duration: 56mg  x 8 kits (24 units) for 28 days & 84mg x 8 kits (24 units) for 28 days based on tolerability 
If no - proceed with submitting to the medical benefits manager first (see support auth info below) 

  1. When submitting for medical benefits submit auth for codes 99215, 99417, S0013 (if Medicare use G2212) 
  2. QTY & Duration: 16 units for 30 days  


Include the proper documentation on the authorization 
  1. Recent Consultation appointment 
  1. Recent Encounter 
  1. Recent PHQ9 (and MADRS if available) 
  2. Any supporting clinical criteria outlined on a letter of medical necessity if not documented within the visit notes. 

Close order and Create a pending case 

  1. Close order request in Athena once PA is submitted using “close” – “other” 
  1. Create pending patient case and route to the department specific Spravato inbox subject lined Pending ePA – Spravato (this will act as your worklist item to check and update regularly) 
  1. Use text macro .spravatoauth in the case description and fill in any current information you can. Any other information can be documented in the action note.  
  1. Keep this patient case open until there is a final outcome. Make daily update on this patient case to centralize all related information and allow anyone to follow behind easily if needed. 

Work the outcome:  
  1. For follow up procedures and communication specific to each outcome please follow the Approvals through appeals sections on the following document : Medication PA Workflow 
  1. Make sure to update the pending case with each action taken until approved then c

  2. Schedule the appointment on the Spravato Schedule 

    1. Use the appointment type that aligns with where the patient is in their treatment plan. 

  3. ase can be closed as completed. 
  1. Denials and appeals can take up 30 days  
Medication ordering and Administration scheduling:

If the order exists as a MEDICATION ORDER in the “meds” tab of the patient's chart queue up the medication order. 
      1. Hamburger menu to the top right of the chart  
      1. “add order group” and select the ordering provider 
      1. Open the “meds” tab and use the arrow next to the Spravato med to bring the med into the order group 
      1. Ensure the pharmacy attached at the “receiver” is the specialty pharmacy 
Schedule the Administration appointment: 
  1.  Spravato appointments are scheduled on the Spravato Schedule.
  2. “Subsequent Spravato Treatment” slots on the providers schedule will be used to freeze corresponding appts.
if no Spravato appt is scheduled at that time admin and provider can and should override that appt and use it for standard med appts**

Schedule the appointment on the Spravato Schedule

  1.       Use the appointment type that aligns with where the patient is in their treatment plan. 
Available appointments: 
      1. Spravato 120 Induction  (typically weeks 1-4) 
      1. Spravato 120 Initial Maintenance (typically weeks 5-8) 
      1. Spravato 120 Ongoing maintenance (typically weeks 9 onward) 
Freeze the providers schedule within the corresponding “Subsequent Spravato Treatment” appt slot using “Spravato” as the freeze option. 

 

** As a part of the automations in Athena, patients will be sent Spravato Consent for treatment.  Please confirm that the patient has completed this form PRIOR to their first Spravato treatment** 


Spravato With Me & REMS Enrollment (savings plan and benefits review):

Spravato with me enrollment form

          1. In person:

            1. (log into Spravato with me > go to dashboard > select “add new patient” > follow prompts no you don’t have a form to upload / Yes the patient is with you / The patient will be signing > obtain the Docusign form”  

        1. Not in person:  

            1. Email link (log into Spravato with me > go to dashboard > select “add new patient” > follow prompts no you don’t have a form to upload > No the patient is not with you > no they did not upload a signed form online > Yes email the link > enter patients email and submit)  


To run the Benefits Investigation: 

      1. Log into Spravato with me portal  
      1. Go to the patient list tab 
      1. Select the specific patients name hyperlink in the first column  
      1. Scroll down to “insurance coverage” and select “run new BI” (VOB can take up to 48 hours sometimes even longer ensure patient communicates to you once this has been completed and check back into Spravato with me regularly.) 


  2. REMS enrollment:  

  1. Enroll in REMS using the REMS Patient Enrollment Form 

  1. Once enrollment is complete, please upload signed enrollment form, or confirmation from Spravato website verifying enrollment.  

      1. Enroll in REMS using the REMS Patient Enrollment Form 
      1. Once enrollment is complete, please upload signed enrollment form, or confirmation from Spravato website verifying enrollment.  

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