Health Plan (7.4) 7.4

P-OPS 11 - Oversight of Automated Review of Pharmacy Non-Certifications

Submited by: Tom Goddard

The Basics

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.

Management Tips

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. 

Accreditation Tips

Desktop Review
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.
Validation Review
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.

  • Health Plan (7.4) 7.4 / 02.19.2021

    P-OPS 12 - Breach Handling

    This standard outlines the requirements for your organization when a privacy breach is discovered. The process must include:Recording the date your organization knew or should have known of the breach;Notifying the privacy and security official(s);Determining whether a breach actually occurred;Once it's determined that a breach did, in fact, occur, Recording the date of the breach;Mitigating the c...

    READ FULL POST
  • Health Plan (7.4) 7.4 / 02.19.2021

    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. O...

    READ FULL POST
  • Health Plan (7.4) 7.4 / 02.19.2021

    P-OPS 10 - Economic Formulary Considerations

    In order to assure that cost issues do not supercede clinical issues, this standard prohibits consideration of economic factors of a medication before its safety efficacy, therapeutic appropriateness, and side effects have been established. Once those issues have been considered, it is appropriate to evaluate equivalent alternative medications and therapies in terms of their impact on health costs...

    READ FULL POST
Top