This measure is important because it tracks the exception requests reviewed by the Pharmacy, Clinical Integrity and Clinical Operations Units and will provide data to support a more efficient and improved clinical review of non-covered codes. The exception request process allows a Vermont Medicaid member, 18 years of age or older, to request coverage for non-covered services or items.

This measure tracks and monitors non-covered code request volumes, clinical category of exception requests, and the clinical review determination of exception requests.  Monitoring the request trends of non-covered codes will allow DVHA to:

• consider code coverage in a timely approach, 
• ensure access to services, and 
• assess service coverage changes and resulting exception request volume increases, in a specific category of service, to support the delivery of quality and cost-effective health care services.   

The data and trendline demonstrates that the majority of exceptions requests are received for medical non-covered codes, followed by pharmacy requests, and the smallest percentage of exception requests are associated with mental health requests. Quarter data reveals the majority of exceptions requests are approved and that CY23 Q2 exception request volumes are trending the highest quarter to date.

Narrative last updated:  02/07/24

• DVHA Exceptions Coordinator
• DVHA Clinical Services Team:  Pharmacy Unit, Clinical Integrity Unit & Clinical Operations Unit
• DVHA Chief Medical Officer
• DVHA Enrolled Providers
• DVHA Member Provider Services Unit
• DVHA Fiscal Agent, Gainwell