Prior Approval Requests in Healthcare

Context for Prior Approval

• A prior approval request (DAP) is required before practicing an act or beginning treatment
• However, if there is a manifest urgency, an act can be practiced or treatment begun, but accompanied by a DAP endorsed with "Act Urgent"
• The DAP must be done no later than day 1 of treatment, and after actual service fulfilment.
• A teleservice for PPC/OAM prior approval requests enables trained pulmonologists and doctors to seek health insurance approval for patients over 16.

Healthcare Professionals

• The Prior Approval PPC – OAM service can be accessed via CPS card through the Amelipro portal
• Pulmonologists and neurologists have direct service access without needing honor-based attestations
• Other medical specialties gain access with an honor-based attestation verifying required prescribing qualifications
• Amelipro and CPS cards provide access to the prior approval request service
• Inputting NIR (social security number) or reading the Vitale card automatically transmits information to the relevant medical service or health insurance scheme

Access via Amelipro

• A link labeled "Accord Préalable PPC – OAM" is available within the "Service Patient" section when a healthcare professional is logged into Amelipro

Tele Service Welcome

• View the history of all DAP requests
• Consult each DAP request
• Conduct DAP searches

Displayed Information

• Includes Name, First name, DAP identifier, and related treatment (PPC or OAM)
• Includes transmission date and status such as:
  • Favorable
  • Unfavorable
  • Deferred for medical advisor review
  • Sent to a scheme other than CPAM

Second Tab

• The second tab for DAP of a patient is for setting up and renewing
• It allows viewing patient DAP history, setting new DAP requests, and renewing former DAPs

Initial DAP Setting

• All data fields are mandatory
• The "Numéro de sécu" and PG/PSG reports must be attached
• The DAP must occur no later than the first day of treatment
• Submitting the form displays a summary before transmitting

Favorable Status

• indicates an approved coverage decision by the Insurance provider that depends on the insured party fulfilling legal service allocation terms

• A prescription must be printed or the recap stored

• When data matches the insurance coverage conditions, immediate approval results

Differed Status

• The request is sent to the medical department for review before decision notice
• A justified decision will be notified within 15 days of the request
• No reply in 15 days is an automatic approval

The DAP request flow for "DAP Initiale (Initial DAP Request)"

• The initial DAP process involves filling out required fields via Amelipro/NIR including
  • NIR
  • PG
  • PSG
  • Symptoms
  • Treatment to be prescribed
• The "Avis Favorable" (approval) results in immediate start
• The "Avis Défavorable" (rejection) results in immediate reply
• The "Avis Différé" (differed reply) result is for a maximum of 15 days
• All these outcomes can approve or deny PPC/OAM prescription

Generating a Prescription (PPC)

• From the approval page, the prescription is generated which requires:
  • Confirming care regarding ALD
  • Specifying "Type PPC"
  • Setting adjustments
  • Brand and models
  • Specifying pressure or interval
  • Treatment length or timelines

Renovation of a PPC/OAM DAP

• A DAP renovation contains two possibilities
  • A 4-month renovation after the initial approval
  • A yearly renovation after the first approval and subsequent 4 month renovation
• All renovations ask for the same fields
• Once completed, the teleservice delivers an immediate outcome
• The doctor will then generate a prescription for the patient in previous modality
• After the twenty eighth month, only a prescription via the "portail presta" is enough

PPC DAP Renovation

• For each renovation you must answer two core questions
  • Improving symptoms
  • Acknowledging patient observance
• If the symptoms have not improved, renewing may be possible if the doctor justifies either:
  • Suffering from car somnolence
  • Suffering severe sleep apnea syndrome

OAM DAP Renovation

• Requires attaching the reunion account of the inspection
• Renewing and completing the form allows printing/sending a prescription