North Carolina Utilization Rules for Opioid and Other Pharmacological Pain Management Treatment
When do the new rules apply?
The rules apply to all affected treatment in all affected claims on or after May 1, 2018.
Affected claims: Any NC claim unless the patient has been receiving a “targeted controlled substance” for more than 12 consecutive weeks immediately prior to 5/1/18.
Affected treatment: Pain management treatment for non-cancer pain in WC claims.
Exception: medications administered in a health care setting.
What’s in the new rules?
Controlled Substance Reporting System (CSRS) mandate – Effective Nov. 1, 2018
- Requires prescribers to check CSRS at certain points in treatment.
Clinical guidelines and preauthorization requirements – Effective May 1, 2018
- Different guidelines for:
- 1st prescription in “acute phase”
- Subsequent prescriptions in “acute phase”
- Prescriptions in “chronic phase”
- Requirement to “consider” prescribing an opioid antagonist in certain scenarios.
- Suggestions to “consider” non-pharmacological treatment and tapering/discontinuation.
- Preauthorization requirements for certain medications prescribed in a “chronic phase”
“Companion Guide” — Provides guidance as to how the Commission expects the rules to be implemented
New Ex Parte Communication Forms – released with the “Companion Guide”
Important Terminology
“Acute Phase” – Treatment within 12 weeks of:
- a compensable injury,
- an aggravation of a compensable injury, or
- a surgery for a compensable injury
(Note that there can be multiple “acute phases” in the same claim.)
“Chronic Phase” – Treatment more than 12 weeks from the beginning of the last “acute phase.”
Transition to Compliance with the Rules
- No “legacy claims” or “legacy period.” (Claims that aren’t affected by the rules will never be affected by the rules).
- For affected claims, Companion Guide recommends a transition period of up to 6 months.
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