I. SCOPE: To establish a process whereby reviews are completed in a timely manner.

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1 Utilization Management Policy & Procedure Subject: Timeframes for Completing Initial Clinical Reviews and Continued Stay or Continued Services Reviews Line of Business: [ X ] Medicaid Effective Date: June 1, 2016 Document Number: HUM Original Approval Date: Replaces HUM Page 1 of 5 Most Recent Revision: June 2016, 9/2016 Next Review Date: 6/2018 Date Reviewed: 6/2016, 12/2016, 6/2017 I. SCOPE: To establish a process whereby reviews are completed in a timely manner. II. POLICY: Providers including attending physicians, attending providers, members, facilities rendering healthcare services, and other ordering providers have the right to expect timely and appropriate utilization management determinations and notifications of those determinations. III. DEFINITIONS: Appropriate Utilization: appropriate care at the appropriate setting Attending Physician: The doctor of medicine or doctor of osteopathic medicine with primary responsibility for the care provided to a patient in a hospital or other health care facility. Attending Provider: The physician or other health care practitioner with primary responsibility for the care provided to a consumer. Authorization or Certification: A determination by an organization that an admission, extension of stay, or other health care service has been reviewed and, based on the information provided, meets the clinical requirements for medical necessity, appropriateness, level of care, or effectiveness under the auspices of the applicable health benefit plan. Behavioral Health/Behavioral Health Care: An umbrella term that includes mental health and substance abuse. Services are provided by those who are licensed by the state and whose professional activities address a client's behavioral issues. Licensed mental health practitioners include psychologists, psychiatrists, social workers, psychiatric nurse practitioners, marriage and family counselors, professional clinical counselors, licensed drug/alcohol abuse counselors and mental health professionals. Case: A specific request for medical or clinical services referred to an organization for a determination regarding the medical necessity and medical appropriateness of a health care service or whether a medical service is experimental/investigational or not. Case Involving Urgent Care: Any request for a utilization management determination with respect to which the application of the time periods for making non-urgent care determinations a) could seriously jeopardize the life or health of the consumer or the ability of the consumer to regain maximum function, or b) in the opinion of a physician with knowledge of the consumer s medical condition, would subject the consumer to severe pain that cannot be adequately managed without the care or treatment that is the subject of the case. Any claim that a physician with knowledge of the claimant's medical condition determines is a claim involving urgent care shall be treated as a claim involving urgent care. 1

2 Concurrent Review: Utilization management conducted during a patient's hospital stay or course of treatment (including outpatient procedures and services). Sometimes called "continued stay review". Date of Receipt: The date on which a claim arrives at an Organization (or, for claims that arrive on a non-business day, the date of the first business day thereafter). Initial Clinical Review: Clinical review conducted by appropriate licensed or certified health professionals. Initial clinical review staff may approve requests for admissions, procedures, and services that meet clinical review criteria, but must refer requests that do not meet clinical review criteria to peer clinical review for certification or non-certification. Sometimes referred to as first level review. Member: A policyholder, subscriber, enrollee or other individual participating in a health benefit plan. Ordering Provider: The physician or other provider who specifically prescribes the health care service being reviewed. Prospective Review: Utilization management conducted prior to a patient s admission, stay, or other service or course of treatment (including outpatient procedures and services). Sometimes called precertification review or prior authorization, prospective review can include prospective prescription drug utilization review. Provider: A licensed health care facility, program, agency, or health professional that delivers health care services. Retrospective Review: Review conducted after services (including outpatient procedures and services) have been provided to the patient. Reviewer(s): The individual (or individuals) selected by the organization to consider a case. All reviewer(s) who are health care practitioners must have the following qualifications: o Active U.S. licensure; o Recent experience or familiarity with current body of knowledge and medical practice; o At least five (5) years of experience providing health care. Utilization Management (UM): Evaluation of the medical necessity, appropriateness, and efficiency of use of health care services, procedures, and facilities. Utilization management encompasses prospective, concurrent and retrospective review; it does not include claims review, even if the organization chooses to conduct utilization review on a claims submission, unless a specific request from the claimant for retrospective review accompanies the claims submission. IV. PROCEDURES: Delegated Responsibilities: None Plan Responsibilities: A. Prospective or prior authorization review is performed on requests for services prior to the service being rendered. HHP maintains a list of services that require prior authorization. All requests are logged for tracking processes, and date and time stamped upon receipt. A prospective/prior authorization review is based solely upon information available to the HHP Reviewer at the time the review is conducted. For prospective/prior-authorization reviews, HHP must send the written determination: (1) As soon as possible based on the clinical situation, but in no case later than 72 hours of the receipt of request for a utilization management determination, if it is a case involving urgent care; or 2

3 (2) Within 14 calendar days of the receipt of request for a utilization management determination, if it is a non-urgent case; and (3) For non-urgent cases, this period may be extended one time by the organization for up to 14 calendar days: (i) Provided that the organization determines that an extension is necessary because of matters beyond the control of the organization (such as a lack of clinical information received with the request); the reasons for the extension as well as the dates the extension started and ended are documented in the case file. (ii) Notifies the provider telephonically or via fax, prior to the expiration of the initial 14 calendar day period, of the circumstances requiring the extension and the date when the plan expects to make a decision; and (iii) If a provider fails to submit necessary information to decide the case by the end of the extension date, and no clinical information was provided with the initial request, an administrative denial for lack of clinical information is to be sent. (If no or insufficient clinical information is received, see the policy Scope of Review Information/Lack of Information HUM ). If some clinical information was sent, but is incomplete, refer the case to the Medical Director. B. Retrospective review is performed on requests where the service(s) have already been rendered. This could be for inpatient or prior authorization services. The majority of these reviews will be performed by the Appeals Coordinator as the service will have been rendered and the claim will have been denied, usually for no prior authorization. However, Harbor will accept and process late inpatient notifications with clinical information for contracted hospitals. In addition, during the inpatient review process, a request may become a retrospective review if a patient has been discharged prior to a determination, e.g., during observation and insufficient information processes. Retrospective reviews are performed based on the information available to the provider at the time the service was rendered. For retrospective review, the organization issues a determination: (1) Within 30 calendar days of the receipt of request for a utilization management determination; (2) This period may be extended one time by the organization for up to 14 calendar days: (i) Provided that the organization determines that an extension is necessary because of matters beyond the control of the organization (such as a lack of clinical information received with the request); the reasons for the extension as well as the dates the extension started and ended are documented in the case file. (ii) Notifies the provider telephonically or via fax, prior to the expiration of the initial 14 calendar day period, of the circumstances requiring the extension and the date when the plan expects to make a decision; and 3

4 (iii) If a provider fails to submit necessary information to decide the case by the end of the extension date, and no clinical information was provided with the initial request, an administrative denial for lack of clinical information is to be sent. (If no or insufficient clinical information is received, see the policy Scope of Review Information/Lack of Information HUM ) If some clinical information was sent, but is incomplete, refer the case to the Medical Director. C. Concurrent reviews are performed for inpatient stays that exceed or may exceed the anticipated discharge date. For concurrent review, the organization adheres to the following time frames: For requests to extend a current course of treatment, the organization issues the determination within: (1) 24 hours of the request for a utilization management determination, if it is a case involving urgent care and the request for extension was received at least 24 hours before the expiration of the currently certified period or treatments; or (2) 72 hours of the request for a utilization management determination, if it is a case involving urgent care and the request for extension was received less than 24 hours before the expiration of the currently certified period or treatments. Clarifying Note: if the request for an extension is: Received at least 24 hours or more before certification expires, notification of the review determination occurs within 24 hours of receipt of the request. Received less than 24 hours before certification expires, notification of the review determination occurs within 72 hours of receipt of the request. (If no or insufficient clinical information is received, see the policy Scope of Review Information/Lack of Information HUM ) Cases meeting the definition of concurrent urgent include in-patient stays wherein the hospital or attending physician requests additional days (continuing stay reviews); lower levels of care such as skilled nursing facilities, rehabilitation services, and home health care services; and behavioral health services when the provider states that such services are required on an urgent basis. Continuing stay review notifications, if approved, must contain the following information: 1. Date of admission or onset of services; 2. Number of additional days or units/visits of services authorized; 3. The new total number of days or units/visits of services authorized; and 4. The next anticipated review date. Cases meeting the definition of concurrent non-urgent include ongoing out-patient services such as PT, OT, Speech, etc. and these types of out-patient services must be completed within 3 business days. D. Initial In-Patient Reviews: HHP s policy requires that, upon notification of an in-patient admission with clinical information, the review and notification must be completed within 1 business day. V. MATERIALS: 4

5 Delegated Responsibilities: Not Applicable Plan Responsibilities: Date Stamper, Tracking Logs, Review Criteria, Documentation Forms VI. REPORTING: Delegated Requirements for Reporting: Not Applicable Plan Reporting Responsibilities: At a minimum, utilization statistics will be reported to the UMC on an annual basis 5