DOH Prior Authorization ‘Minimum Data’ Policy Intends to Reduce Denials and Appeals

Situation Report | July 20, 2021

The state Department of Health (DOH) will implement a Prior Authorization Minimum Data Set Policy to improve the submission of Prior Authorization (PA) Requests to Medicaid Managed Care Plans (MMCPs), effective August 1, 2021.

MMCPs include Managed Long Term Care Plans, Mainstream Medicaid Managed Care Plans, HIV Special Needs Plans (HIV SNP) and Health and Recovery Plans (HARP).

According to DOH, this policy will reduce the number of service request denials and appeals filed solely due to lack of basic information needed to process the request. It will do so by creating a standard prior authorization data set with the minimum information required for MMCPs to accept and begin reviewing a PA request.

MMCPs who choose to implement this policy must follow the guidelines. If an MMCP does not implement this policy, the MMCP must continue to accept and make a determination on all provider PA requests received.

Questions about this policy may be referred to

This policy will be posted on the MRT II website under Medicaid Managed Care Plan Policies and MLTC Policies.