Health Plan (7.4) 7.4
P-OPS 11 - Oversight of Automated Review of Pharmacy Non-Certifications
If your organization conducts automated review in connection with drug management, you must have written P&Ps that describe the oversight mechanism for such automated review. That oversight must be conducted by both a senior clinician and a clinical oversight body. That oversight body can be, but need not be, the P&T Committee.
The oversight of automated review must be active and well-documented. Of particular importance is the examination of the relationship between automated review and the appeals process. The evaluation of the automated review process and the linkages to appeals must be conducted no less frequently than annually in order to be considered active and meaningful.
Your P&P on this topic should spell out oversight responsibilities quite clearly. Make sure you address linkages to appeals; it will not be sufficient to show mere oversight of the automated review mechanism.
You'll want to submit quite a bit of documentation for desktop review. In addition to the relevant P&Ps, you'll want a thorough description of the methodology by which the senior clinician and clinical oversight body evaluate automated review and appeals linkages. In addition, submit a job description for the senior clinician who oversees the review and linkages. Make sure that job description includes this function. Finally, submit minutes of the clinical oversight body demonstrating that it has, in fact, implemented the oversight required by this standard.
The onsite review will consist of interviews of the clinical staff person conducting the oversight and the staff members supporting the P&T Committee. In addition, the reviewer will want to see documentation of the annual evaluation.