PA case sampling (8/30 NCQA methodology)

PSHP will select eight prior authorization requests for the initial IRR test and present identical cases to clinical pharmacists; if reviewers do not achieve >=90% agreement on those 8 cases, PSHP will present 22 additional cases for resampling (total 30) following the NCQA '8/30' rule.

• Initial sample: 8 PA requests selected by PSHP Vice President of Clinical Pharmacy Services or designee
• If <90% agreement on initial 8 cases → present 22 additional cases (total 30) for resampling

Step therapy applicability — not applicable

Step therapy rules do not apply in this policy; the document addresses inter-rater reliability testing of PA decision-making rather than imposing specific step therapy requirements.

Audit documentation and record retention

Document consensus outcomes, meeting minutes and action plans, and retain electronic approval records; final documentation of consensus and minutes will be included and submitted to NCQA, and electronic approval retained in the system is considered equivalent to a signature.

• Record minutes from Clinical Staff Meeting that documents inconsistencies, agreed action plans (guideline development, training, process improvement) and final consensus
• Submit documented minutes and action plans to NCQA
• Retain electronic application/approval records (electronic approval considered equivalent to a signature)

Risk from inconsistent PA application

If consistent application of PA criteria is not achieved (IRR <90%), the IRR process may identify potentially avoidable utilization and lead to inconsistent medical necessity determinations; identified inconsistencies must be addressed at a Clinical Staff Meeting with an action plan to correct variation.

• Present findings demonstrating inconsistency at a Clinical Staff Meeting with all clinical pharmacists
• Develop and document an action plan (e.g., guideline development, training, process improvements) to reduce variation