FirstCarolinaCare has a mandatory generic policy. This policy applies to brand medications that have generic equivalents. In order for patients to save the most money, the generic equivalent should be prescribed and dispensed. This allows the patient to be charged only the generic copayment. If the provider or patient feels a brand medication is necessary, the patient will pay the applicable copayment plus the cost difference between the brand and generic medication.

The mandatory generic policy does not apply to “Narrow Therapeutic Index” (NTI) medications. According to the North Carolina Board of Pharmacy, NTI medications must be refilled with the same medication from the same manufacturer that was last dispensed unless the pharmacist has permission from the provider and patient to use another manufacturer. For NTI medications, the member will pay only the applicable copayment.

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While many people believe that precertification plans are in place at managed care companies solely to reduce utilization, that is generally not the case. It is certainly not the case at FirstCarolinaCare. These programs began in response to major geographic and practice variation that could not be explained on any clinical basis. Reports of hysterectomy rates differing severalfold between states and cardiovascular surgery rates that were triple in one city as compared to a neighboring city pushed managed-care companies to incorporate processes to ensure serviceswere provided based on generally accepted clinical criteria.

At FirstCarolinaCare, we work to help our members get what they need, when they need it, in a cost-effective manner and, most importantly, through the application of evidence-based clinical pathways. FirstCarolinaCare believes that providing evidencebased care can improve outcomes and reduce costs, ultimately decreasing the rate of premium growth. This helps keep premiums more affordable for employers so they can continue to offer health insurance to their employees – thus slowing the rate of growth of the uninsured population.

For precertification purposes, FirstCarolinaCare uses InterQual (IQ) criteria. These nationally recognized criteria provide clinical guidelines and information that help determine the appropriateness of proposed services. The criteria are used to approve care, not deny it. They are based on analysis of well-researched medical studies and are updated annually. Prior to the release of criteria, clinical consultants who have not been part of the initial review process assess and validate the criteria content for clinical accuracy. When practice patterns suggest there may be a variation in the local standard of care, FirstCarolinaCare has a process for additional review. The IQ criteria in question are reviewed first by our medical directors and then by the medical management committee, FirstQIC. Practicing physicians serving on FirstQIC review the literature and the criteria, and can make appropriate recommendations to FirstCarolinaCare. Through this process, several sets of criteria were either created or modified to reflect local physician input within the last year.

The precertification process begins with a call or fax to FirstCarolinaCare precertification nurses. These nurses are educated and trained in the use of IQ criteria and in the collection of pertinent information to apply those criteria. The nurses never deny a request for any service. They either approve it if it meets the IQ criteria, or refer it to a medical director for review. The vast majority of precertification requests are approved by the nurses, and the majority of those sent to physician reviewers are also approved.

Denials overwhelmingly occur because insufficient clinical information is provided by the requestor, generally the provider’s office. Other common causes for denials include a lack of trial of conservative management, a lack of trial of less invasive, less costly testing, and sometimes because a more expensive test such as MRI may be more definitive or more appropriate than a less expensive tests such as a CT scan.

Once a request for services is approved or denied, letters are sent to the member and the requesting provider. Nonapproval letters outline the reason for the denial, as well as the appeals procedures required by North Carolina law. However, since the most common cause for denial is inadequate information, if additional information is available, contacting the precertification nurses with that information may be the most appropriate and efficient response to a non-approval letter. Additionally, if desired, the precertification nurse can arrange for a peer-to-peer conversation with the medical director on call.

In summary, precertification is used by FirstCarolinaCare to increase the value our members receive for their premium dollars, and to encourage the practice of evidence-based medicine and clinical pathways executed through the use of clinical criteria.

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