CID management. Ms. Rosa Moran May 31, 2012 Division of Workers Compensation 1515 Clay Street, 17 th Floor Oakland, CA 94612

Transcription

1 CID management Ms. Rosa Moran May 31, 2012 Division of Workers Compensation 1515 Clay Street, 17 th Floor Oakland, CA Re: Submission of Utilization Review Policy and Procedures Dear Ms..Moran, At Comprehensive Industrial Disability Management (CID) we strive to ensure our clients employees receive best-practice clinical care through our utilization review program: the RITE Solution. Our solution is a web-based program that allows our clinical peer reviewers to effectively and efficiently review submitted requests for authorization while focusing on quality of care. The CID UR program follows the HIPAA Privacy Rules, URAC WCUM Standards as well as all California labor code and regulations. Our utilization management solution is designed around a core set of customizable technologies and processes that allow the integration of utilization review procedures into claims management. Consequently, the UR information is immediately available to the claims personnel. In CID s effort to comply with California Labor Code and Regulations we respectfully submit the following Utilization Review Policy & Procedures on behalf of our organization as well as our contracted clients. Respectfully Submitted by, Todd Andrew Director of Clinical Operations CID Management P.O. Box 4379 Westlake Village, California extension todd.andrew@cidmcorp.com CID Management Utilization Review Policy and Procedures 1 Revised May 2012

2 CID s Mission Statement Providing Intelligent UR Solutions That Ensure Best Clinical Practice While Managing Cost of Care CID Management Utilization Review Policy and Procedures 2 Revised May 2012

3 Table of Contents: Part 1. Required Elements & Description of the Utilization Review Process Page A. Medical Director (a)(1) 4 B. Utilization Management Process Description (a)(2) 5 C. Utilization Management Process Description for Expedited Reviews (a)(2) D. Specific Criteria Utilized in the Decision Making Process (a)(3) 14 B. Qualifications and Functions of Personnel Involved in the Development and 15 Maintenance of the Utilization Review Plan (a)(4) C. Qualifications and Functions of Personnel Involved in the Implementation of 17 the Utilization Review Plan (a)(4) D. Description of Claims Administrator s Process (a)(5) 20 I. Prior Authorization Process & Claims Administrator Process By Client 21 Part 2. CID Policies and Procedures. A. Reference List for Specific Policies Addressing CA Labor Code and 45 Regulations B. CID Policies and Procedures 47 Part 3. Sample Letters 397 Upon request by the public, CID shall make available this complete utilization review plan, consisting of the policies and procedures, and description of the utilization review process. CID Management Utilization Review Policy and Procedures 3 Revised May 2012

4 PART 1. Required Elements & Description of the Utilization Review Process A. Medical Director (a)(1) CID s Medical Director is Jonathan S. Rutchik, MD, MPH California Medical License: # G85804 Address: P.O. Box 4379 Westlake Village, CA Telephone: Dr. Rutchik's focus is neurological illness, workplace injuries and environmental exposure. He is in private practice in the San Francisco Bay area and holds a position as an Assistant Clinical Professor in the Division of Occupational Medicine, in the Department of Internal Medicine at the University of California at San Francisco. Dr. Rutchik completed an Internship through the Department of Labor, OSHA, Washington DC: Office of Occupational Medicine. He is a Board Certified Diplomate of the American Board of Preventative Medicine (Occupational and Environmental Medicine) and Board Certified Diplomate of the American Board of Psychiatry and Neurology. In addition, he is a California Qualified Medical Examiner. CID Management Utilization Review Policy and Procedures 4 Revised May 2012

5 B. Utilization Management Process Description (a)(2) The following is an abbreviated description of the utilization management process followed by CID. Each section references the associated CID Policy so that the reader may refer to the appropriate policy for further details. Toll Free Telephone & Toll Free Fax Access for Submission of Requests CID shall maintain toll free telephone and toll free fax access from 9:00 AM to 5:30 PM, in all time zones in which they do business, on normal business days for providers to request authorization for medical services and appeals considerations. For purposes of this section, CID defines normal business days as defined in LC and in section 9 of the Civil Code. CID shall maintain toll free telephone with voice mail, and toll free fax access, during all non- business hours for providers to request authorization for medical services and appeals considerations. CID employees and contractors shall return all mail inquiries, voice mail messages, messages, or fax messages within 1 business day of receipt. Please see CID Policies 5000, 5005, 5010, 5020, and 5030 for more details. Date of Receipt Written requests for authorization shall be deemed to have been received by facsimile on the date the request was received if the receiving facsimile electronically date stamps the transmission. If there is no electronically stamped date recorded, then the date of receipt shall be deemed to be the date the request was transmitted. A request for authorization transmitted by facsimile after 5:30 P.M. Pacific Time shall be deemed to have been received by the claims administrator on the following business day as defined in Labor Code section and in section 9 of the civil Code. Where the request for authorization is received by mail and a proof of service by mail exists, the request shall be deemed to have been received five (5) days after the deposit in the mail at a facility regularly maintained by the United States Postal Service. Where the request is delivered via certified mail, return receipt mail, the request shall be deemed to have been received on the receipt date entered on the return receipt. In the absence of a proof of service by mail or a dated return receipt, the request shall be deemed to have been received on the date stamped on the document by the recipient. Electronic Review File Creation Upon receipt of a request for authorization or appeals consideration, the client or CID nonclinical administrative staff shall create an electronic review file. The review file shall contain all elements associated with the review including, but not limited to: stakeholders, activity log, relevant dates pertaining to the review, documents received, generated correspondences, past reviews, etc. Please see attached CID Policy 3010 for more details. CID Management Utilization Review Policy and Procedures 5 Revised May 2012

6 Pre-Review Screening Should any necessary elements be missing from the review as it is being created, CID nonclinical administrative staff may perform pre-review screening. If so, they shall ensure that pre-review screening occurs within 2 business days of receiving the request for authorization or appeals consideration. The CID staff shall record all information gathered in pre-review screening in the CID utilization management electronic review file. CID defines pre-review screening as including any of the following: Collection of structured clinical data defined as clinical information that is precise and permits exact matching against explicit medical terms, diagnoses or procedure codes, or other explicit choices, without the need for interpretation Asking scripted clinical questions; Accepting responses to scripted clinical questions Taking specific action, including amendment of items contained in the electronic review file as explicitly linked to each of the possible responses Pre-review screening shall not include any of the following: Applying clinical judgment or interpretation; Accepting unstructured clinical information; Deviating from script; Engaging in unscripted clinical dialogue; Asking clinical follow up questions; Issuing determinations of any kind A copy of the Pre-Review Screening Script may be found on page Please see CID Policy 3100 for more details. Initial Clinical Review Initial Clinical Reviewers perform first level review on requests for authorization. They review the clinical documentation and apply clinical review criteria, approved by the Medical Director and Clinical Review Committee, to the request for authorization. Initial Clinical Reviewers may issue certifications if the request for authorization matches the clinical review criteria and is medically necessary. Initial Clinical Reviewers may not process non-certifications but rather shall forward all reviews for which they are not recommending certification, to a Clinical Peer Reviewer. Initial Clinical Reviewers may request additional clinical information, which they deem reasonable and necessary to complete utilization management, from the provider via fax, phone, mail or . Please see CID Policies and 3200 for more details. CID Management Utilization Review Policy and Procedures 6 Revised May 2012

7 Clinical Peer Review Clinical Peer Reviewers perform second or third level review on requests for authorization, reconsiderations or appeals consideration. They review the clinical documentation and apply clinical review criteria, approved by the Medical Director and Clinical Review Committee, to the request for authorization. Clinical Peer Reviewers issue determinations of medical necessity. Clinical Peer Reviewers may request additional clinical information, which they deem reasonable and necessary to complete utilization management, from the provider via fax, phone, mail or . In the case of concurrent review, medical care shall not be discontinued until the requesting physician has been notified of the decision and a care plan has been agreed upon by the requesting physician that is appropriate for the medical needs of the injured worker. Please see CID Policy , 3300 and 3600 for more details. Quality Assurance Quality Control Reviewers Prior to releasing the UR determination to stakeholders, reviews completed by CID initial clinical reviewers and clinical peer reviewers shall be reviewed by QAQC reviewers. QAQC reviewers shall perform day to day quality assurance and quality control monitoring of: a. Reviewing internal consistency within the review to ensure that the review does not contradict itself. b. Reviewing completeness of the review to ensure that it addresses all elements of care requested by the requesting physician. c. Reviewing guidelines applied for relevance to the requested care. d. Reviewing guidelines for appropriate referencing. e. Reviewing the determination for grammar, punctuation, and spelling. If the QAQC Reviewer notes non-material changes, such as spelling, grammar, or punctuation, they shall make the non-material changes to the review and shall release the review to stakeholders. However, if the QAQC reviewer notes material changes, such as incomplete reviews or incorrect guidelines, they shall re-assign the review to the initial clinical reviewer or clinical peer reviewer for correction. The QAQC reviewers shall note any common errors of specific initial clinical reviewers or clinical peer reviewers and shall communicate this to the Clinical Director. Please see Policy 4000 for more details. Clinical Review Criteria CID utilizes clinical review criteria recommended by the CID Clinical Review Criteria Committee and approved by the CID Medical Director. The current clinical review criteria utilized are: a. State of California Medical Treatment Utilization Schedule b. American College of Occupational and Environmental Medicine s Occupational Medicine Practice Guidelines, Second Edition (ACOEM) c. The Official Disability Guidelines (ODG) CID Management Utilization Review Policy and Procedures 7 Revised May 2012

8 d. The National Guidelines Clearinghouse e. Department of Industrial Accidents Health Care Services Board Treatment Guidelines, Commonwealth of Massachusetts f. Colorado Department of Labor and Employment Medical Treatment Guidelines g. Delaware Health Care Services Guidelines h. Minnesota Department of Labor and Industry i. Washington State Department of Labor and Industries Medical Treatment Guidelines j. Wyoming Workers Safety and Compensation Division Treatment k. The National Institute of Health s PubMed scientific literature database. Please see CID Policy 1100 for more details. Requests for Additional Information During the utilization management process, non-clinical administrative staff, initial clinical review staff or clinical peer reviewers may determine that additional information must be requested from the provider in order to make a determination of medical necessity. In this case, the request for additional information shall be sent within 2 business days of receiving the request for authorization from either the claims administrator or the provider, or sooner if required to comply with regulatory timeframes. The CID System shall generate the appropriate correspondences which shall be delivered to the required stakeholders in a manner and a timeframe consistent with the requirements in 8CCR If the client has indicated that they do not want CID to distribute correspondences to a party via a method specified by law, the client shall assume the responsibility of distributing these correspondences themselves. Please see CID Policy 3700 for more details. CID Management Utilization Review Policy and Procedures 8 Revised May 2012

9 Determination Letters Upon conclusion of the review, the CID system shall generate the determination letters. All determination correspondences shall contain the following elements: a. The date on which a decision is made b. A description of the specific course of proposed medical treatment for which authorization was requested c. A specific description of the medical treatment services certified, if any. If for a hospital stay, this shall include the number of days or units of service certified, if any, the next anticipated review point, if any, the new total number of days or services approved, if any, and the date of admission or onset of services, if any. d. The name of the initial clinical review staff and/or clinical peer reviewer that made the determination e. For all reviews with an adverse determination, the determination correspondence shall also include: i. A clinical rationale which shall include: 1. A clear and concise explanation of the reason for the decision 2. The principle reason regarding medical necessity ii. A description of the medical criteria or guidelines used iii. A written copy of the relevant portion of the criteria or guidelines used iv. Details about the claims administrator s internal utilization review appeals process, if any, and a clear statement that the appeal process is on a voluntary basis v. The specialty of the reviewer, if any vi. The CID contact telephone number vii. The CID hours of availability viii. For California claims, the following elements will be added: 1. A clear statement that any dispute shall be resolved in accordance with the provisions of Labor Code section 4062, and that an objection to the utilization review decision must be communicated by the injured worker or the injured worker s attorney on behalf of the injured worker to the claims administrator in writing within 20 days of receipt of the decision. It shall further state that the 20-day time limit may be extended for good cause or by mutual agreement of the parties. The letter shall further state that the injured worker may file an Application for Adjudication of Claim and Request for Expedited Hearing, DWC Form 4, showing a bona fide dispute as to entitlement to medical treatment in accordance with sections 10136(b)(1), 10400, and The following mandatory language: "If you want further information, you may contact the local state Information and Assistance office by calling [enter district I & A office telephone number closest to the injured worker] or you may receive recorded information by calling The following mandatory language You may also consult an attorney of your choice. Should you decide to be represented by an attorney, you may or may not receive a larger award, but, unless you are determined to be ineligible for an award, the attorney's fee will be deducted from any award you might receive for disability benefits. The decision to be represented by an attorney is yours to make, but it is voluntary and may not be necessary for you to receive your benefits." CID Management Utilization Review Policy and Procedures 9 Revised May 2012

10 4. The following mandatory language "If you disagree with the utilization review decision and wish to dispute it, you must send written notice of your objection to the claims administrator within 20 days of receipt of the utilization review decision in accordance with Labor Code section You must meet this deadline even if you are participating in the claims administrator s internal utilization review appeals process. 5. The following statement: In the event that you would like to discuss this decision with the reviewer, please call x 790 so that a convenient time may be arranged for this discussion. All reviewers are available for at least four hours per week during normal business days from 9:00 a.m. to 5:30 p.m. PST per regulations (k). On all correspondences to non-physician providers of goods or service, the clinical rationales and guidelines shall be removed consistent with CA Labor Code and Regulations The CID System shall generate the appropriate correspondences which shall be delivered to the required stakeholders in a manner and a timeframe consistent with 8CCR If the client has indicated that they do not want CID to distribute correspondences to a party via a method specified by law, the client shall assume the responsibility of distributing these correspondences themselves. In such instance, CID shall inform the client of regulatory requirements regarding timelines and parties to be served communications. Copies of generic determination letters have been included following the Policies and Procedures section of this plan. Please note that each client may require customization to the overall content and format of the letters; however CID ensures that all customized letters are compliant with the labor code and regulations. Please see CID Policy 3800 for more details. Timeframes The CID RITE software is designed to ensure that reviews are completed within the regulatory timeframes. The system automatically calculates the due date based on type of review (prospective, concurrent, retrospective), date of receipt of request, presence or absence of notification of extension of due date, and the date of receipt of all necessary information reasonably required to make the determination. The Director of Production, Senior Utilization Management Supervisors and QAQC reviewers monitor the timeframes of all reviews to ensure that they are completed timely. In California, timeframes are monitored for compliance with 8CCR and review due dates are set to ensure completion in a timely fashion. 1.0 Prospective decisions shall be made in a timely fashion that is appropriate for the nature of the injured workers condition, not to exceed five (5) business days from the date of receipt of the written request for authorization. CID Management Utilization Review Policy and Procedures 10 Revised May 2012

11 1.1 If appropriate information, which is necessary to render a decision, is not provided with the original request for authorization, such information may be requested by a reviewer or non-physician reviewer within five (5) business days from the date of receipt of the written request for authorization. 1.2 If the reasonable information is received prior to the fourteenth (14 th ) calendar day following the date of receipt of the written request for authorization, the reviewer shall make a decision within five (5) business days of the receipt of the information.. In no event shall the determination be made more than 14 days from the date of receipt of the original request for authorization by the health care provider. 1.3 If the reasonable information requested is not received within 14 calendar days of the date of the original request for authorization, a reviewer may deny the request with the stated condition that the request will be reconsidered upon receipt of the information requested. 1.4 In no event shall the determination be made more than 14 calendar days from the date of receipt of the original request for authorization from the health care provider. 1.5 If the review is expedited, the decision shall be made in a timely fashion appropriate to the injured worker s condition, not to exceed 72 hours after the receipt of the written information reasonably necessary to make the determination. 2.0 Concurrent decisions shall be made in a timely fashion that is appropriate for the nature of the injured workers condition, not to exceed five (5) business days from the date of receipt of the written request for authorization. 2.1 If appropriate information, which is necessary to render a decision, is not provided with the original request for authorization, such information may be requested by a reviewer or non-physician reviewer within five (5) business days from the date of receipt of the written request for authorization. 2.2 If the reasonable information is received prior to the fourteenth (14 th ) calendar day following the date of receipt of the written request for authorization, the reviewer shall make a decision within five (5) business days of the receipt of the information.. In no event shall the determination be made more than 14 days from the date of receipt of the original request for authorization by the health care provider. 2.3 If the reasonable information requested is not received within 14 calendar days of the date of the original request for authorization, a reviewer may deny the request with the stated condition that the request will be reconsidered upon receipt of the information requested. 2.4 In no event shall the determination be made more than 14 calendar days from the date of receipt of the original request for authorization from the health care provider. CID Management Utilization Review Policy and Procedures 11 Revised May 2012

12 2.5 If the review is expedited, the decision shall be made in a timely fashion appropriate to the injured worker s condition, not to exceed 72 hours after the receipt of the written information reasonably necessary to make the determination. 3.0 For retrospective reviews, decisions shall be communicated to the requesting physician within 30 days of receipt of the medical information that is reasonably necessary to make this determination. 3.1 If appropriate information, which is necessary to render a decision, is not provided with the original request for authorization, such information may be requested by a reviewer or non-physician reviewer within thirty (30) calendar days from the date of receipt of the written request for authorization. 3.2 If the reasonable information is received prior to the thirtieth (30 th ) calendar day following the date of receipt of the written request for authorization, the reviewer shall make a decision within thirty (30) calendar days of the receipt of the information. 3.3 If the reasonable information requested is not received within 30 calendar days of the date of the original request for authorization, the reviewer may deny the request with the stated condition that the request will be reconsidered upon receipt of the information requested. Please see CID Policy 3900 for more details. CID Management Utilization Review Policy and Procedures 12 Revised May 2012

13 Utilization Management Process Description for Expedited Reviews (a)(2) CID shall complete prospective or concurrent utilization management of expedited reviews, either request for authorization or appeals considerations, in a timely fashion appropriate to the injured worker s condition, not to exceed 72 hours after the receipt of the written information reasonably necessary to make the determination. For the purposes of this section, decisions related to expedited review refer to the following situations: a. When the injured worker s condition is such that the injured worker faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other major bodily function, or; b. The normal timeframe for the decision-making process would be detrimental to the injured worker s life or health or could jeopardize the injured worker s permanent ability to regain maximum function. Please note that the provider must indicate the need for an expedited review upon submission of the request. In emergency situations posing an immediate threat to the health and safety of patients, CID shall inform the party that failure to obtain prior authorization for emergency health care services is not an acceptable basis for refusal to cover medical services provided to treat and stabilize an injured worker, and that emergency health care services may be subject to retrospective utilization review. If the party requires that prospective utilization review be performed in situations where the health or safety of a patient is under immediate threat, the call shall be transferred directly to the Clinical Director, in his/her absence, to the Director of Production/Senior Utilization Management Supervisor. The Clinical Director, Director of Production, or a Senior Utilization Management Supervisor, shall assign the initial clinical reviewer, clinical peer reviewer, and QAQC reviewer that are immediately available for reviews. The availability of each reviewer shall be confirmed by the Clinical Director, Director or Production, or Senior Utilization Management Supervisor by telephone. Until the review is completed, the Clinical Director, Director of Production, or Senior Utilization Management Supervisor, shall evaluate the progress of the review by checking its status at intervals not to exceed 30 minutes. Immediately upon reaching a determination, the CID system shall generate a determination letter that shall be immediately faxed to the provider. The Clinical Director, Director of Production, or Senior Utilization Management Supervisor, shall further contact the requesting provider via telephone to verify the receipt of the determination to ensure its arrival. Please see CID Policy 3900 for more details. CID Management Utilization Review Policy and Procedures 13 Revised May 2012

14 Specific Criteria Utilized in the Decision Making Process (a)(3) CID utilizes clinical review criteria recommended by the Clinical Review Criteria Committee and approved by the CID Medical Director. Clinical review criteria used by CID reviewers on California reviews are consistent with the Medical Treatment Utilization Schedule. The current clinical review criteria utilized are: a. State of California Medical Treatment Utilization Schedule b. American College of Occupational and Environmental Medicine s Occupational Medicine Practice Guidelines, Second Edition (ACOEM) c. The Official Disability Guidelines (ODG) d. The National Guidelines Clearinghouse e. Department of Industrial Accidents Health Care Services Board Treatment Guidelines, Commonwealth of Massachusetts f. Colorado Department of Labor and Employment Medical Treatment Guidelines g. Delaware Health Care Services Guidelines h. Minnesota Department of Labor and Industry i. Washington State Department of Labor and Industries Medical Treatment Guidelines j. Wyoming Workers Safety and Compensation Division Treatment k. The National Institute of Health s PubMed scientific literature database. Materials from NIH PubMed are not to be used as clinical review criteria unless they rise to the level of evidence described in 8CCR9792.2(c)(1)(A); and unless there are no other sources of scientific evidence available (e.g., source of last resort) Please see CID Policy 1100 for more details. CID Management Utilization Review Policy and Procedures 14 Revised May 2012

15 B. Qualifications and Functions of Personnel Involved in the Development and Maintenance of the Utilization Review Plan (a)(4) CID s Utilization Review Plan was developed, and is maintained and updated, by the CID Medical Director in conjunction with the CID Policy and Procedures Committee. Medical Director Qualifications: Jonathan S. Rutchik, MD, MPH. California Medical License: # G85804 Dr. Rutchik's focus is neurological illness, workplace injuries and environmental exposure. He is in private practice in the San Francisco Bay area and holds a position as an Assistant Clinical Professor in the Division of Occupational Medicine, in the Department of Internal Medicine at the University of California at San Francisco. Dr. Rutchik completed an Internship through the Department of Labor, OSHA, Washington DC: Office of Occupational Medicine. He is a Board Certified Diplomate of the American Board of Preventative Medicine (Occupational and Environmental Medicine) and Board Certified Diplomate of the American Board of Psychiatry and Neurology. In addition, he is a California Qualified Medical Examiner. Functions: Through oversight of the CID Polices and Procedures committee, the CID Medical Director ensures that the utilization management plan remains compliant with the CA Labor Code and Regulations. The Medical Director is responsible for all decisions made in the utilization review process. CID Policy and Procedures Committee Members Director of Clinical Operations Qualifications: Todd Andrew, DC. California Chiropractic License: # DC Dr. Andrew's focus is the overall operations of the CID medical cost containment programs. He oversees CID s national network of physicians and operations staff to provide customized technology and process driven solutions for the workers' compensation industry. Dr. Andrew graduated with his Doctor of Chiropractic degree (summa cum laude) from PCCW as well as an undergraduate degree from the University of Calgary. He has maintained private practice in San Francisco, CA, and has distinguished himself as an Assistant Professor at Palmer College where he taught in the departments of Diagnosis, Technique and Practice. Dr. Andrew previously served as a Qualified Medical Examiner and holds certifications as an Industrial Disability Examiner, Injury Prevention Specialist and Ergonomic Consultant. Functions: Dr. Andrew is a member of the CID Policy and Procedures Committee. Clinical Director Qualifications: Robert Ward, DC. California Chiropractic License: # DC Dr. Ward's focus is the day to day operations and quality management of the CID UR program. His secondary focus is the appropriate integration and delivery of complementary CID Management Utilization Review Policy and Procedures 15 Revised May 2012

16 and alternative medicine within workers' compensation. He has recently served as a Professor at the Southern California University of Health Sciences where he taught in the departments of Diagnosis and Anatomy. Dr. Ward has served as a Qualified Medical Examiner, as the past editor of The Journal of Chiropractic Education, and as a Clinical Peer Reviewer at CID. Functions: The Clinical Director serves as Chair of the CID Policy and Procedures Committee and reports to the Medical Director. The Clinical Director ensures that the CID Policy and Procedures Committee meets as needed to review the CID policies and procedures of the utilization management program. The Clinical Director conveys the recommendations of the committee to the Medical Director for final approval and adoption. Director of Production: Qualifications: Vaghar Haghiri. Mr. Haghiri is a Director of Production at CID. In that role, he helped develop and maintain processes to manage 250,000+ patient reviews, scheduling and work flow for 75+ physicians, and client accounts from both public and private sectors. Mr. Haghiri carries over 10 years experience in customer service and management support and 5 years experience in utilization management. Functions: Mr. Haghiri is a member of the CID Policy and Procedures Committee. CID Management Utilization Review Policy and Procedures 16 Revised May 2012

17 C. Qualifications and Functions of Personnel Involved in the Implementation of the Utilization Review Plan (a)(4) Medical Director. Qualifications: Jonathan S. Rutchik, MD, MPH. California Medical License: # G85804 Dr. Rutchik's focus is neurological illness, workplace injuries and environmental exposure. He is in private practice in the San Francisco Bay area and holds a position as an Assistant Clinical Professor in the Division of Occupational Medicine, in the Department of Internal Medicine at the University of California at San Francisco. Dr. Rutchik completed an Internship through the Department of Labor, OSHA, Washington DC: Office of Occupational Medicine. He is a Board Certified Diplomate of the American Board of Preventative Medicine (Occupational and Environmental Medicine) and Board Certified Diplomate of the American Board of Psychiatry and Neurology. In addition, he is a California Qualified Medical Examiner. Functions: The Medical Director is responsible for credentialing of the clinical staff, clinical oversight and quality management of CID s utilization management program. Consistent with 8CCR , the Medical Director is responsible for all decisions made in the utilization review process. CID s Medical Director fulfills this responsibility by monitoring the clinical staff as well as by ensuring that the policies and procedures utilized within the utilization management process are compliant with the CA Labor Code and Regulations. Through administration and oversight of the Quality Assurance program and all CID utilization management committees, the CID Medical Director ensures that all CID staff and contractors adhere to the utilization management plan through all clinical and non-clinical facets. Director of Clinical Operations Qualifications: Todd Andrew, DC. California Chiropractic License: # DC Dr. Andrew's focus is the overall operations of the CID medical cost containment programs. He oversees CID s national network of physicians and operations staff to provide customized technology and process driven solutions for the workers' compensation industry. Dr. Andrew graduated with his Doctor of Chiropractic degree (summa cum laude) from PCCW as well as an undergraduate degree from the University of Calgary. He has maintained private practice in San Francisco, CA, and has distinguished himself as an Assistant Professor at Palmer College where he taught in the departments of Diagnosis, Technique and Practice. Dr. Andrew previously served as a Qualified Medical Examiner and holds certifications as an Industrial Disability Examiner, Injury Prevention Specialist and Ergonomic Consultant. Functions: The Director of Clinical Operations oversees the general administration of the Utilization Management program. The Director of Clinical Operations facilitates the integration of the utilization management process, the utilization management technology and the utilization management policies and procedures in the CID utilization management system. CID Management Utilization Review Policy and Procedures 17 Revised May 2012

18 Clinical Director Qualifications: Robert Ward, DC. California Chiropractic License: # DC Dr. Ward's focus is the day-to-day operations and quality management of the CID UR program. His secondary focus is the appropriate integration and delivery of complementary and alternative medicine within workers' compensation. He has recently served as a Professor at the Southern California University of Health Sciences where he taught in the departments of Diagnosis and Anatomy. Dr. Ward has served as a Qualified Medical Examiner, as the past editor of The Journal of Chiropractic Education, and as a Clinical Peer Reviewer at CID. Functions: The Clinical Director facilitates the day-to-day operations of the Utilization Management program. Acting as the Medical Director s senior staff member in the Utilization Management program, the Clinical Director assists in supervising all staff and contractors and serves on all committees. Initial Clinical Reviewers Qualifications: The general qualifications of Initial Clinical Reviewers includes: a health profession degree such as, but not limited to, MD, DO, DC, DPM, LAc, PhD, RN; a current license or certification to practice a health profession; and two years professional experience preferred. Initial Clinical Reviewers must be licensed by a State or by the District of Columbia. Functions: Initial Clinical Reviewers perform first level review on requests for authorization. They review the clinical documentation and apply clinical review criteria, approved by the Medical Director and Clinical Review Committee, to the request for authorization. Initial Clinical Reviewers may issue certifications if the request for authorization matches the clinical review criteria and is medically necessary. Initial Clinical Reviewers may not process non-certifications but rather shall forward all reviews for which they are not recommending certification, to a Clinical Peer Reviewer. Initial Clinical Reviewers may request additional clinical information, which they deem reasonable and necessary to complete utilization management, from the provider via fax, phone, mail or . Clinical Peer Reviewers Qualifications: The general qualifications of Clinical Peer Reviewers includes: a health profession degree such as, but not limited to, MD, DO, DC, DPM, LAc, PhD; a current license or certification to practice a health profession; five years professional experience preferred; board certification, preferred where applicable, for appeals consideration. Clinical Peer Reviewers must be licensed by a State or by the District of Columbia. Functions: Clinical Peer Reviewers perform second or third level review on requests for authorization, reconsiderations or appeals consideration. They review the clinical documentation and apply clinical review criteria, approved by the Medical Director and Clinical Review Committee, to the request for authorization. CID Management Utilization Review Policy and Procedures 18 Revised May 2012

19 Clinical Peer Reviewers issue determinations of medical necessity. Clinical Peer Reviewers may request additional clinical information, which they deem reasonable and necessary to complete utilization management, from the provider via fax, phone, mail or . Quality Assurance Quality Control Reviewers Qualifications: The general qualifications of QAQC Reviewers includes: a health profession degree such as, but not limited to, MD, DO, DC, DPM, LAc, PhD, RN; a current license or certification to practice a health profession; and two years professional experience preferred. Functions: QAQC Reviewers perform quality assurance review on reviews at any stage of the utilization management process. If the QAQC Reviewer identifies a review with quality assurance issues, they shall return the review to the Initial Clinical Reviewer or Clinical Peer Reviewer for revision. QAQC Reviewers are required to notify the Clinical Director of common quality assurance quality control issues. Director of Production / Senior Utilization Management Supervisors Qualifications: The general qualifications of the Director of Production and Senior Utilization Management Supervisors includes a Bachelor s degree, one year of experience in administrative or customer service, or an equivalent combination of education and experience. Functions: The Director of Production and Senior Utilization Management Supervisors are responsible for providing administrative support services and supervision of non-clinical staff. These individuals oversee the Utilization Management administrative department including: management of all aspects of non-clinical staff personnel including hiring, training, supervision and performance evaluation; performance of QAQC on administrative utilization management procedures including timeframe adherence; oversight of customer satisfaction and customer relations; and communication and consultation with the Medical Director and Clinical Director in regard to performance of daily tasks. Non-Clinical Administrative Staff Qualifications: The general qualifications of the Non-Clinical Administrative Staff includes a Bachelor s degree, one year of experience in administrative or customer service, or an equivalent combination of education and experience. Functions: The Non-Clinical Administrative Staff are responsible for providing administrative support for processes within utilization management and for performing customer service for the various stakeholders in the utilization management process. CID Management Utilization Review Policy and Procedures 19 Revised May 2012

20 D. Description of Claims Administrator s Process (Including (a)(5)) A percentage of CID clients choose to outsource their entire Utilization Management process to CID, whereas others choose to perform initial utilization management functions, such as certifying some requests for authorization, in house. For those clients who outsource their entire Utilization Management process to CID, the claims administrators are responsible for notifying all parties how to contact CID for utilization management functions. For inquiries outside of business hours, the claims administrators shall record a message on their voice mail providing CID s contact information including phone and fax numbers. Further, the client shall maintain a 24 hour voice mail system and incoming fax line to receive requests for authorization during and after business hours. For these clients, as soon as the claims administrator receives a request for authorization, they shall immediately forward it to CID for completion. For those clients who choose to perform initial utilization management functions in-house, said clients must determine if they require CID s Medical Director, or a Medical Director of their own, to oversee their in-house utilization management process. If the client wishes to have CID s Medical Director oversee their in-house utilization management process, they must comply with CID Policy 9000 which was developed by CID s Medical Director. CID Policy 9000, which is attached to this plan, outlines the procedures the clients must follow in the utilization management process. Please refer to CID Policy 9000 for a complete description of the claims administrator s procedures. If the client wishes to have a non-cid Medical Director oversee their in-house utilization management process, the client must separately file a letter with the Administrative Director which shall include a copy of the policies and procedures they will follow in the performance of utilization management. These policies and procedures must be developed and approved by their own Medical Director. This letter shall further identify CID as their Utilization Review Organization for all requests which are forwarded for peer review. For these clients, CID s Medical Director shall only be responsible for requests forwarded to CID for review. CID s Medical Director shall not be responsible for any portion of the utilization management process performed prior to the review being submitted to CID and shall not be responsible for any determinations rendered by the client. Further details about each client s specific claims administrator s processes have been included in the pages that follow. CID Management Utilization Review Policy and Procedures 20 Revised May 2012

21 Client City of Glendale Client letter on file with AD Yes PMMC letter on file with AD - Yes CID (URO) policy & procedures on file with AD Yes Prior authorization process The City of Glendale utilizes a prior authorization process as follows: Prior Authorization The following services and/or procedures shall be considered pre-authorized by the City of Glendale. The provider shall not be required to submit requests through utilization review for these services. For all services and/or procedures not addressed on this list, please submit requests for authorization directly to the claims administrator. Physical Therapy Up to 9 physical therapy visits per claim Up to 9 occupational therapy sessions per claim Chiropractic Therapy Up to 6 chiropractic therapy sessions per claim Medications Over the counter medications Ibuprofen and NSAIDs Up to one month prescription of non-narcotic pain medication administered in first month of injury. Up to one month prescription of muscle relaxants administered in first month of injury where the patient has acute muscle spasm on clinical exam. Diagnostic Testing Initial x-ray study of a body part if any red-flags listed below are present. Red Flags: * Direct trauma to body part(s) * Suspected fracture or dislocation All Specialty Consultations For accepted body parts/conditions immediately following injury, for the following: requests for orthopaedics, neurology, surgical intervention, and PM&R Claims Administrator Approvals The City of Glendale claims administrators may issue approvals on requests for authorization that are not addressed by the prior authorization process. The steps that they follow to issue these approvals are outlined in CID s filing with the Administrative Director s office and can be found in CID Policy The approvals issued by the claims administrators, in compliance with CID Policy 9000, are supervised by CID s medical director. Diagnostic Testing for Fire Fighters Only (does not includes Firefighter Management personnel): MRI CID Management Utilization Review Policy and Procedures 21 Revised May 2012

22 CT scans EMG/NCS EKG Upon request of the treating physician the claims examiners, with the approval of the HR Director, will be allowed to approve EKGs, CT Scans, MRIs, and EMG/NCS, (excluding surface EMGs (SEMGs)), when said diagnostic examinations can reasonably reduce lost time and overtime expenditures, approval will be granted expeditiously. Utilization Review Organization All requests received by the City of Glendale which the adjustors feel may require physician review are forwarded to Preferred Medical Management Consultants. PMMC reviews the requests following steps outlined in PMMC s and CID s filings with the AD. The approvals issued by PMMC, in compliance with CID Policy 9000, are supervised by CID s medical director. All requests received by PMMC which are determined to require physician review are forwarded to CID. CID Management Utilization Review Policy and Procedures 22 Revised May 2012

23 Client City of Los Angeles Client letter on file with AD Yes CID (URO) policy & procedures on file with AD Yes Prior authorization process The City of Los Angeles uses a prior authorization process as follows: On July 1, 2010 the City of Los Angeles will implement a Prior Authorization Program. The Prior Authorization Program allows providers in the City s First Care Panel to provide routine medical procedures on accepted and delayed claims without Utilization Review based on their adherence to the Medical Treatment Utilization Schedule (MTUS) and evidence-based medicine. All treatment must follow the Title 8 CCR MTUS criteria. The Prior Authorization Program will include the following procedures or ancillary services: PLEASE NOTE: All of the following procedures and ancillary services must be provided by the City of Los Angeles Contracted Managed Care Providers on the attached list. For MRI or CT Scan Civilian and Fire Claims: Med Focus Police Claims: One Call Medical For Physical Therapy, Occupational Therapy, or Chiropractic Visits Align Networks For Medication and Durable Medical Equipment Cypress Care Physical Medicine Up to 24 Physical Therapy, Occupational Therapy, or Chiropractic Sessions Up to 18 Acupuncture Sessions Psychology Up to 12 Psychological Visits for an accepted non-trauma-related pscyh claim Up to 24 Psychological Visits for an accepted trauma-related pscyh claim Office Visits & Specialty Referrals Routine Office Visit and Follow Ups Specialty Referral Imaging and Diagnostics Initial MRI or CT Scan EMG/NCS Plain View X-Rays Medications 1-year of prescription drugs per Pharmacy Benefit Management (PBM) formulary 1-year of Vicodin and/or Flexeril 1 time 60-day authorization of non-formulary prescription drugs, except Class III/IV narcotics Pain pump refills when pain pump implant was previously approved. CID Management Utilization Review Policy and Procedures 23 Revised May 2012

24 Durable Medical Equipment Basic DME: Splits, Crutches, Braces, cane, walker, standard wheelchair rental, off the shelf braces, walking boots, slings, hot and cold packs. Surgery Surgery for removal of non-spine related hardware. Routine surgeries of the upper extremity Surgical services: In the event that a surgical procedure has been authorized, the associated services listed below are considered to be subject to prior authorization, and do not require separate authorization: Surgery of any body part Complete blood count (CBC) Urinalysis (UA) Pre-operative clearance performed by the surgeon (not by any other provider) Up to 18 sessions of post-operative physical medicine (PT, OT, or chiropractic) Surgery of the foot or ankle Inpatient stay of up to 2 days Ankle foot orthosis (AFO) Cam walker Cold packs Walking aid (cane, crutches, brace or walker) Surgery of the knee or leg Inpatient stay of up to 4 days Bathing seat Cold pack Continuous passive motion (CPM) during inpatient stay Continuous flow cryotherapy (up to 7 days) Walking aid (cane, crutches, brace or walker) Surgery of the hip/pelvis Inpatient stay of up to 5 days Assistant surgeon Cold pack Continuous flow cryotherapy (up to 7 days) Walking aid (cane, crutches, brace or walker) Surgery of the hand/wrist Cold pack Surgery of the elbow/forearm Cold pack Surgery of the shoulder Inpatient stay of up to 2 days Surgery of the lumbar spine Assistant surgeon Inpatient stay of up to 4 days CID Management Utilization Review Policy and Procedures 24 Revised May 2012

25 Surgery of the cervical spine Assistant surgeon Inpatient stay of up to 2 days Cold pack No provider notification letters will be sent by the City claims administrators or designated Utilization Review Organization for the procedures or services that fall under this Program. Claims Administrator Approvals The City of Los Angeles in-house claims administrators, and the claims administrators working on the City of Los Angeles account at the designated third party administrator, may issue approvals on requests for authorization. The steps that they follow to issue these approvals are outlined in CID s filing with the Administrative Director s office and can be found in CID Policy The approvals issued by the claims administrators, in compliance with CID Policy 9000, are supervised by CID s medical director. Utilization Review Organization All requests received by the City of Los Angeles which they determine to require physician review are forwarded to CID. CID Management Utilization Review Policy and Procedures 25 Revised May 2012

26 Client - City of Santa Monica Client letter on file with AD Yes CID (URO) policy & procedures on file with AD Yes Prior authorization process The City of Santa Monica does not utilize a prior authorization process. Claims Administrator Approvals The City of Santa Monica has not made known to CID the processes they follow in issuing claims administrator approvals, nor the name of the medical director they are utilizing to supervise the approvals*. Please contact the City of Santa Monica if this information is required. * The administrative approvals issued by the City of Santa Monica staff are not supervised by the CID medical director. Consequently, we are not a party to any administrative approvals issued. Utilization Review Organization All requests received by the City of Santa Monica which they determine to require physician review are forwarded to CID. CID Management Utilization Review Policy and Procedures 26 Revised May 2012

27 Client Contra Costa County Client letter on file with AD Yes CID (URO) policy & procedures on file with AD Yes Prior authorization process Contra Costa utilizes a prior authorization process as follows: Prior Authorization The following services and/or procedures shall be considered pre-authorized. The provider shall not be required to submit requests through utilization review for these services. For all services and/or procedures not addressed on this list, please submit requests for authorization directly to the claims administrator. Physical Therapy / Chiropractic Care / Acupuncture Up to 12 physical therapy visits per claim Up to 12 post-operative physical therapy visits per claim, if applicable Up to 12 chiropractic visits per claim Up to 12 acupuncture visits per claim Medications Over the counter medications including Ibuprofen and NSAIDs. Up to two week prescription of non-narcotic pain medication administered in first month of injury. Up to two weeks prescription of muscle relaxants administered in first month of injury where the patient has acute muscle spasm on clinical exam. Continued prescription refills for patients when the claims administrator has given pre-approval for longer term medication use Diagnostic Testing (Diagnostic testing must be performed by Contra Costa County designated vendors.) Initial x-ray study of a body part if any red-flags listed below are present. Initial MRI of a body part if any red-flags listed below are present. Initial CT study of a body part if any red-flags listed below are present. Initial EMG/NCV study for diagnostic confirmation of Carpal Tunnel Syndrome where clinical signs exist supporting diagnosis of median nerve entrapment. Initial EMG/NCV study for diagnostic confirmation of nerve root compression where clinical signs of myotome, dermatome, or reflex changes exist. Red Flags: * Recent history of significant trauma to body part * Suspected fracture or dislocation * Suspected infection * Suspected tumor * Rapidly progressive neurologic deficit * Vascular compromise Durable Medical Equipment (DME supplies must be provided by Contra Costa County designated vendors.) DME items, costing $500 or less, when prescribed by Contra Costa County designated occupational medicine providers. DME items, costing $200 or less, if prescribed by non-contra Costa County designated providers. Miscellaneous CID Management Utilization Review Policy and Procedures 27 Revised May 2012

28 Care consistent with stipulated award Care consistent with AME/PQME report recommendations Care consistent with second opinion consultations approved and authorized by Contra Costa County Claims Administrator Approvals Contra Costa County claims administrators may issue approvals on requests for authorization that are not addressed by the prior authorization process. The steps that they follow to issue these approvals are outlined in CID s filing with the Administrative Director s office and can be found in CID Policy The approvals issued by the claims administrators, in compliance with CID Policy 9000, are supervised by CID s medical director. Utilization Review Organization All requests received by Contra Costa County which require physician review are forwarded to CID. CID Management Utilization Review Policy and Procedures 28 Revised May 2012

29 Client: E. J. Gallo Client letter on file with AD Yes CID (URO) policy & procedures on file with AD Yes Prior authorization process E. J. Gallo does not utilize a prior authorization process. Claims Administrator Approvals E. J. Gallo claims administrators may issue approvals on requests for authorization. The steps that they follow to issue these approvals are outlined in CID s filing with the Administrative Director s office and can be found in CID Policy The approvals issued by the claims administrators, in compliance with CID Policy 9000, are supervised by CID s medical director. Utilization Review Organization All requests received by E. J. Gallo which require physician review are forwarded to CID. CID Management Utilization Review Policy and Procedures 29 Revised May 2012

30 Client Fontana Unified School District Client letter on file with AD Yes PMMC letter on file with AD - Yes CID (URO) policy & procedures on file with AD Yes Prior authorization process Fontana Unified School District (FUSD) utilizes a prior authorization process as follows: Prior Authorization Per CA Department of Industrial Relations, Title 8, Section 5.5.1, Utilization Review Standards, Section (a)(5). The following services and/or procedures shall be considered authorized. The provider shall not be required to submit requests through utilization review for these services. For all services and/or procedures not addressed on this list, please submit requests for authorization directly to the claims administrator. Physical Therapy/Occupational Therapy First 8 physical therapy visits for the neck and spine First 6 physical therapy visits for all other body parts to include the knees, ankle, etc. Any request in excess of 8 visits for the spine and neck, or 6 visits for all other body parts, should be forwarded to Fontana Unified School District. First 8 Occupational Therapy visits for the hand and foot only. Post-Operative Physical Therapy/Occupational Therapy First 10 physical therapy/occupational therapy sessions post-operatively Medications Over the counter medications including Ibuprofen and NSAIDs. Up to two week prescription of non-narcotic pain mediation administered in the first two months of injury Diagnostic Testing (Diagnostic testing must be performed by FUSD designated vendors.) X-ray study of a body part if any red-flags listed below are present. Initial MRI of a body part if any red-flags listed below are present. Initial CT study of a body part if any red-flags listed below are present. Initial EMG/NCV study for diagnostic confirmation of Carpal Tunnel Syndrome where clinical signs exist supporting diagnosis of median nerve entrapment. Initial EMG/NCV study for diagnostic confirmation of nerve root compression where clinical signs of myotome, dermatome, or reflex changes exist. Red Flags: * Recent history of significant trauma to body part * Suspected fracture or dislocation * Suspected infection * Suspected tumor * Rapidly progressive neurologic deficit * Vascular compromise Durable Medical Equipment (DME supplies must be provided by FUSD designated vendors) CID Management Utilization Review Policy and Procedures 30 Revised May 2012

31 DME items costing $100 or less. As a reminder, FUSD has its own durable medical equipment provider. Please send us your prescription in writing and we will process the request for you. All Specialty Consultations: For accepted body parts/conditions immediately following injury, for the following: * Request for orthopaedics, neurology, surgical intervention, and PM&R AME/QME: Requests for med-legal evaluations/diagnostics Claims Administrator Approvals FUSD claims administrators may issue approvals on requests for authorization that are not addressed by the prior authorization process. The steps that they follow to issue these approvals are outlined in CID s filing with the Administrative Director s office and can be found in CID Policy The approvals issued by the claims administrators, in compliance with CID Policy 9000, are supervised by CID s medical director. Utilization Review Organization All requests received by FUSD which the adjustors feel may require physician review are forwarded to peer review. The approvals issued by PMMC, in compliance with CID Policy 9000, are supervised by CID s medical director. All requests received by PMMC which are determined to require physician review are forwarded to CID. CID Management Utilization Review Policy and Procedures 31 Revised May 2012

32 Client Great West Casualty Company Client letter on file with AD Yes PMMC letter on file with AD - Yes CID (URO) policy & procedures on file with AD Yes Prior authorization process Great West Casualty Company utilizes a prior authorization process as follows: Prior Authorization The following services and/or procedures shall be considered pre-authorized by Great West Casualty Company. The provider shall not be required to submit requests through utilization review for these services. For all services and/or procedures not addressed on this list, please submit requests for authorization directly to the claims administrator. Physical Therapy Up to 6 physical therapy visits per claim Medications Over the counter medications including Ibuprofen and NSAIDs. Up to two week prescription of non-narcotic pain medication administered in first month of injury. Up to two weeks prescription of muscle relaxants administered in first month of injury where the patient has acute muscle spasm on clinical exam. Continued prescription refills for patients when the claims administrator has given pre-approval for longer term medication use Diagnostic Testing Initial x-ray study of a body part if any red-flags listed below are present. Red Flags: * Recent history of significant trauma to body part * Suspected fracture or dislocation Claims Administrator Approvals Great West Casualty Company claims administrators may issue approvals on requests for authorization that are not addressed by the prior authorization process. The steps that they follow to issue these approvals have been defined by Great West Casualty Company.. The approvals issued by the claims administrators, in compliance with CID Policy 9000, are supervised by CID s medical director. Utilization Review Organization All requests received by Great West Casualty Company which the adjustors feel may require physician review are forwarded to Preferred Medical Management Consultants. PMMC reviews the requests following steps outlined in PMMC s and CID s filings with the AD. The approvals issued by PMMC, in compliance with CID Policy 9000, are supervised by CID s medical director. All requests received by PMMC which are determined to require physician review are forwarded to CID. CID Management Utilization Review Policy and Procedures 32 Revised May 2012

33 Client Gallagher Bassett Client letter on file with AD Yes PMMC letter on file with AD - Yes CID (URO) policy & procedures on file with AD Yes Prior authorization process Gallagher Bassett utilizes a prior authorization process as follows: Prior Authorization The following services and/or procedures shall be considered pre-authorized by Gallagher Bassett. The provider shall not be required to submit requests through utilization review for these services. For all services and/or procedures not addressed on this list, please submit requests for authorization directly to the claims administrator. Physical Therapy Up to 6 physical therapy visits per claim Medications Over the counter medications including Ibuprofen and NSAIDs. Up to two week prescription of non-narcotic pain medication administered in first month of injury. Up to two weeks prescription of muscle relaxants administered in first month of injury where the patient has acute muscle spasm on clinical exam. Continued prescription refills for patients when the claims administrator has given pre-approval for longer term medication use Diagnostic Testing Initial x-ray study of a body part if any red-flags listed below are present. Red Flags: * Recent history of significant trauma to body part * Suspected fracture or dislocation Claims Administrator Approvals Gallagher Bassett claims administrators may issue approvals on requests for authorization that are not addressed by the prior authorization process. The steps that they follow to issue these approvals have been defined by Gallagher Bassett. The approvals issued by the claims administrators, in compliance with CID Policy 9000, are supervised by CID s medical director. Utilization Review Organization All requests received by Gallagher Bassett which the adjustors feel may require physician review are forwarded to Preferred Medical Management Consultants. PMMC reviews the requests following steps outlined in PMMC s and CID s filings with the AD. The approvals issued by PMMC, in compliance with CID Policy 9000, are supervised by CID s medical director. All requests received by PMMC which are determined to require physician review are forwarded to CID. CID Management Utilization Review Policy and Procedures 33 Revised May 2012

34 Client Los Angeles Municipal Transportation Authority Client letter on file with AD Yes CID (URO) policy & procedures on file with AD Yes Prior authorization process Los Angeles Municipal Transportation Authority does not utilize a prior authorization process. Claims Administrator Approvals Los Angeles Municipal Transportation claims administrators may issue approvals on requests for authorization that are not addressed by a prior authorization process. The steps that they follow to issue these approvals have been defined by Los Angeles Municipal Transportation. Any approvals issued by the claims administrators, in compliance with CID Policy 9000, are supervised by CID s medical director. Utilization Review Organization All requests received by Los Angeles Municipal Transportation which they determine to require physician review are forwarded to CID. CID Management Utilization Review Policy and Procedures 34 Revised May 2012

35 Client Mainstay Business Solutions / Blue Lake Insurance Services Client letter on file with AD Yes CID (URO) policy & procedures on file with AD Yes Prior authorization process Mainstay Business Solutions / Blue Lake does not utilize a prior authorization process. Claims Administrator Approvals The claims administrators on the Mainstay Business Solutions / Blue Lake claims send all requests for authorization through Intercare s utilization review process. A nurse case manager and a nurse assistant, working under the direction of Intermed s Medical Director, review the requests and approve them if consistent with guidelines. Utilization Review Organization All requests received by Mainstay Business Solutions / Blue Lake which they determine to require physician review are forwarded to CID. CID Management Utilization Review Policy and Procedures 35 Revised May 2012

36 Client State Farm Insurance Client letter on file with AD Yes CID (URO) policy & procedures on file with AD Yes Prior authorization process State Farm does not utilize a prior authorization process. Claims Administrator Approvals State Farm claims administrators may issue approvals on requests for authorization. The steps that they follow to issue these approvals are outlined in CID s filing with the Administrative Director s office and can be found in CID Policy The approvals issued by the claims administrators, in compliance with CID Policy 9000, are supervised by CID s medical director. Utilization Review Organization All requests received by State Farm which require physician review are forwarded to CID. CID Management Utilization Review Policy and Procedures 36 Revised May 2012

37 Client State Fund Client letter on file with AD Yes CID (URO) policy & procedures on file with AD Yes Prior authorization process State Fund uses a prior authorization process as follows: State Fund provides some MPN physicians the authority to perform routine medical procedures without utilization review. Passport participants shall provide treatment consistent with the MTUS found in Title 8 CCR All Physicians participating in the UR Passport Program are part of the following industrial medical groups: Kaiser Permanente, US Heath Works and Concentra. The program may be expanded to include additional physicians at a later date. Eligible doctors may proceed with the majority of treatments without need for utilization review. Prior Authorization With the exceptions noted below, treatment provided by physicians eligible for the State Fund UR Passport Program, and that is consistent with the MTUS found in Title 8 CCR shall be considered pre-authorized. The following services and/or procedures shall not be considered pre-authorized. The provider shall be required to submit requests through utilization review for these services. For all services and/or procedure on this list, please submit requests for authorization directly to the claims administrator. All spinal surgeries Spine Procedures (IDET, discogram, facet injections) Spinal cord stimulators and implantable pain pumps Epidural injections (more than 3 pre year to a region) Open (non-scope) surgeries to knees/shoulders (No UR is required for arthroscopies, foreign body removal, and incision and drainage ) Long term opiate use (more than 90 days) High dose opiates (more than 120mg of morphine equivalent per day or more than 40 mg methadone per day) Home health care and attendant care Compound medications and medical foods In-patient pain management program Weight loss clinics (other than Weight Watchers and in-house weight loss programs) food products not covered The following DME: dynamic splinting, lymphedema, H-wave, Interferential units, power mobility devices/beds/spas [unless rental] No provider notification letters will be sent by the State Fund claims administrators or designated Utilization Review Organization for the procedures or services that fall under this Program. Claims Administrator Approvals The State Fund in-house staff may issue approvals on requests for authorization. The approvals issued by the State Fund staff are supervised by State Fund s medical director. Utilization Review Organization CID Management Utilization Review Policy and Procedures 37 Revised May 2012

38 Requests received by State Fund which they determine to require physician review are forwarded to CID, or to another URO contracted with State Fund. CID Management Utilization Review Policy and Procedures 38 Revised May 2012

39 Client - Teichert Client letter on file with AD Yes CID (URO) policy & procedures on file with AD Yes Prior authorization process Teichert does not utilize a prior authorization process. Claims Administrator Approvals Teichert has not made known to CID the processes they follow in issuing claims administrator approvals, nor the name of the medical director they are utilizing to supervise the approvals*. Please contact Teichert if this information is required. * The administrative approvals issued by the Teichert staff are not supervised by the CID medical director. Consequently, we are not a party to any administrative approvals issued. Utilization Review Organization All requests received by Teichert which they determine to require physician review are forwarded to CID. CID Management Utilization Review Policy and Procedures 39 Revised May 2012

40 Client The Reny Company Client letter on file with AD Yes PMMC letter on file with AD - Yes CID (URO) policy & procedures on file with AD Yes Prior authorization process The Reny Company does not utilize a prior authorization process. Claims Administrator Approvals The Reny Company performs bill review and other cost containment services on behalf of their contracted clients. One component of these cost containment solutions is the performance of utilization review. The Reny Company staff do not issue approvals on requests for authorization received from providers, but rather forward all requests to PMMC for review. Utilization Review Organization All requests received by The Reny Company are forwarded to Preferred Medical Management Consultants. PMMC reviews the requests following steps outlined in PMMC s and CID s filings with the AD. The approvals issued by PMMC, in compliance with CID Policy 9000, are supervised by CID s medical director. All requests received by PMMC which are determined to require physician review are forwarded to CID. CID Management Utilization Review Policy and Procedures 40 Revised May 2012

41 Client Ensign Facility Services, including: Summerfield Healthcare Center Park View Gardens Sonoma Healthcare Center Cloverdale Healthcare Center Northbrook Healthcare Center Ukiah Convalescent Hospital Southland (SNF) and Southland Living (ALF) Royal Crt Healthcare Center (Berryman) Whittier Hills Healthcare Center Panorama Gardens (Beverly Manor) SNF Arbor Glen Care Center Premier Care and Rehabilitation Center Atlantic Memorial Healthcare Center Shoreline Healthcare Center Lemon Grove Care and Rehabilitation Center Rose Villa Care Center Brookfield Healthcare Center Victoria Healthcare Center Palomar Healthcare Center Brookside Healthcare Center Sea Cliff Healthcare Center Claremont Care Center Arroyo Vista Nursing Center Vista Knoll Spec Care Facility Glenwood Care Center Victoria Care Center Palm Terrace Healthcare Center Upland Rehabilitation Center Client letter on file with AD Yes CID (URO) policy & procedures on file with AD Yes Prior authorization process Ensign Facility Services does not utilize a prior authorization process. Claims Administrator Approvals Ensign Facility Services claims administrators may issue approvals on requests for authorization that are not addressed by the prior authorization process. They may choose to process these approvals as outlined in CID s Policy 9000 on file with the Administrative Director s office. The approvals issued by the claims administrators, in compliance with CID Policy 9000, are supervised by CID s medical director. Utilization Review Organization All requests received by Ensign Facility Services which they determine to require physician review are forwarded to CID or another peer review vendor. CID Management Utilization Review Policy and Procedures 41 Revised May 2012

42 Client City of Simi Valley Client letter on file with AD Yes PMMC letter on file with AD - Yes CID (URO) policy & procedures on file with AD Yes Prior authorization process The City of Simi Valley utilizes a prior authorization process as follows: Prior Authorization The following services and/or procedures shall be considered pre-authorized by the City of Simi Valley. The provider shall not be required to submit requests through utilization review for these services. For all services and/or procedures not addressed on this list, please submit requests for authorization directly to the claims administrator. Physical Therapy/Occupational Therapy Up to 6 physical/occupational therapy visits per claim Post Operative Physical Therapy/Occupational Therapy Up to 12 physical/occupational therapy visits per claim Chiropractic Care Up to 12 chiropractic sessions Medications Over the counter medications including Ibuprofen and NSAIDs. Up to two week prescription of non-narcotic pain medication administered in first month of injury. Up to two weeks prescription of muscle relaxants administered in first month of injury Continued prescription refills up to 90 days for patients when the claims administrator has given preapproval for longer term medication use Diagnostic Testing (Diagnostic tests must be performed by a City of Simi Valley designated vendor) Initial x-ray study of a body part if any red-flags exist Specialist Appointments Orthopedic Consultations shall be approved as long as it is to examine an injury or illness accepted in the Workers Compensation claim Durable Medical Equipment (DME supplies must be provide by the City of Simi Valley s designated vendors) Post surgical DME Corticosteroid injections (in non-diabetic patients): Elbow: single injection in cases of severe pain from epicondylitis Knee: three injections or less if the patient has osteoarthritis Shoulder: three injections or less if the patient has rotator cuff disease CID Management Utilization Review Policy and Procedures 42 Revised May 2012

43 Claims Administrator Approvals The City of Simi Valley claims administrators may issue approvals on requests for authorization that are not addressed by the prior authorization process. The steps that they follow to issue these approvals are outlined in CID s filing with the Administrative Director s office and can be found in CID Policy The approvals issued by the claims administrators, in compliance with CID Policy 9000, are supervised by CID s medical director. Utilization Review Organization All requests received by the City of Simi Valley which the adjustors feel may require physician review are forwarded to reviewer level. For those reviews forwarded to Preferred Medical Management Consultants and CID, the requests will be processes following steps outlined in PMMC s and CID s filings with the AD. The approvals issued by PMMC, in compliance with CID Policy 9000, are supervised by CID s medical director. All requests received by PMMC which are determined to require physician review are forwarded to CID. CID Management Utilization Review Policy and Procedures 43 Revised May 2012

44 Reference List for Specific Policies Addressing CA Labor Code and Regulations. LC (a) CID Policy 1100 (b) CID Policy 1100 (c) CID Policy 1100 (d) Administrative. No CID policy required. (1) Administrative. No CID policy required (2) Administrative. No CID policy required (e) CID Policy 1100 LC (a) Administrative. No CID policy required (b) Administrative. No CID policy required (c) CID s utilization review process is governed by the attached policies and procedures. This letter is on file the Administrative Director and shall be disclosed, if requested by the employer to employees, physicians and the public upon request. CID Policy 1100 addresses the clinical review criteria. (d) CID Policy 3700 addresses requests for information. The Medical Director, and his role in the utilization management process is addressed in this letter. (e) CID Policy (f) CID Policy (1) CID Policy (2) CID Policy (3) CID Policy (4) CID Policy (5) CID Policy (g) Administrative. No CID policy required. (1) CID Policy 3800; CID Policy (2) CID Policy 3800; CID Policy (3) Administrative. No CID policy required. (A) CID Policy (B) CID Policy (4) CID Policy (5) CID Policy 3700; CID Policy 3800; CID Policy (h) CID Policy 5005; CID Policy (i) Administrative. No CID policy required. 8 CCR: Administrative. No CID policy required (a) Administrative. No CID policy required. (1) Addressed in this letter. (2) Addressed in this letter. CID Policies (3) Addressed in this letter. CID Policy 1100 (4) Addressed in this letter. CID Policies (5) Addressed in this letter. CID Policy 9000 as specified in this letter. (b) Administrative. No CID policy required. (1) Addressed in this letter. CID Policy (2) CID Policy (3) CID Policies 3100, 3200, 3700, 3900, (c) Addressed in this letter. CID Management Utilization Review Policy and Procedures 44 Revised May 2012

45 (d) Utilization review plan is posted on-line or is available upon request. (1) Utilization review plan is posted on-line or is available upon request (a) Administrative. No CID policy required. (1) CID Policy (2) CID Policy (3) CID Policy (4) CID Policy (a) CID Policies 3000, (1) CID Policy (2) CID Policy (b) Administrative. No CID policy required. (1) CID Policy (2) CID Policies 3700 and (A) CID Policy (3) CID Policy (4) CID Policy (5) Administrative. No CID policy required. (c) CID Policy (d) Administrative. No CID policy required. (e) CID Policies 3000 and (1) Administrative. No CID policy required. (2) CID Policy (f) CID Policy (g) Administrative. No CID policy required. (1) Administrative. No CID policy required. (A) CID Policy (B) CID Policy (C) CID Policy (2) CID Policy (3) CID Policies 3700, 3800, (4) CID Policies 3700, 3800, (h) CID Policies 5000, 5005, 5010, 5020, (i) CID Policy (j) CID Policy (1) CID Policy (2) CID Policy (3) CID Policy (4) CID Policy (5) CID Policy (6) CID Policy (7) CID Policy (8) CID Policy (9) CID Policy (k) CID Policy (l) CID Policy Administrative. No CID policy required. CID Management Utilization Review Policy and Procedures 45 Revised May 2012

46 Tab Policy # Description Date Implemented Latest Revision Date Latest review date Definitions 3/15/06 4/25/12 4/25/ Policy and Procedure Review and Update 3/15/06 4/21/09 4/22/ Clinical Review Criteria 3/15/06 6/8/10 4/22/ Conflict of Interest 3/15/06 6/5/07 4/22/ Utilization Management Labor Code and Regulations Compliance California: through Illinois: through Massachusetts: through Tennessee: through Utah: through /15/06 6/5/07 4/22/ Confidentiality 3/15/06 6/16/09 4/22/12 Texas: Grievances 3/15/06 3/16/11 4/22/12 Texas: Non Clinical Administrative Staff Credentialing 3/15/06 6/5/07 4/22/ Non Clinical Administrative Staff Initial Paperwork 3/15/06 6/5/07 4/22/ Non Clinical Administrative Staff Training 3/15/06 1/29/08 4/22/ Non Clinical Administrative Staff Assessment 3/15/06 1/27/11 4/22/ Delegation of Non-Clinical Functions 4/20/08 4/20/08 4/22/ Initial Clinical Reviewer Staff Credentialing Tennessee: Texas: /15/06 3/10/11 4/22/ Initial Clinical Reviewer Initial Paperwork 3/15/06 3/16/11 4/22/ Initial Clinical Reviewer Training 3/15/06 1/29/08 4/22/ Initial Clinical Reviewer Assessment 3/15/06 3/11/11 4/22/ Delegation of Initial Clinical Review Functions 4/20/08 5/14/09 4/22/ Clinical Peer Review Credentialing California: Massachusetts: Tennessee: Texas: /15/06 3/11/11 4/22/ Clinical Peer Review Initial Paperwork 3/15/06 3/16/11 4/22/ Clinical Peer Review Training 3/15/06 5/14/09 4/22/ Clinical Peer Review Assessment 3/15/06 3/11/11 4/22/12 MasterList-1

47 Delegation of Clinical Peer Review Functions 4/20/08 5/14/09 4/6/12 Massachusetts: Tennessee: Texas: QAQC Review Staff Credentialing 3/15/06 3/11/11 4/22/ QAQC Reviewer Initial Paperwork 3/15/06 3/16/11 4/22/ QAQC Reviewer Training 3/15/06 1/29/08 4/22/ QAQC Reviewer Assessment 3/15/06 3/11/11 4/22/ Delegation of QAQC Review Functions 4/20/08 4/20/08 4/22/ Receipt of Request for Utilization Management Services 3/15/06 1/29/08 4/24/12 California: Massachusetts: Telephonic Inquiry Regarding Utilization Management Services 3/15/06 6/5/07 4/24/ Utilization Management Electronic Review File 3/15/06 6/5/07 4/24/ Pre-Review Screening 3/15/06 5/14/12 5/14/12 California: Initial Clinical Review 3/15/06 7/14/09 4/24/12 Massachusetts: Tennessee: Texas: Clinical Peer Review 3/15/06 5/1/08 4/24/12 California: Massachusetts: Tennessee: Texas: Appeals Consideration 3/15/06 1/29/08 4/24/2012 California: through Massachusetts: Tennessee: Texas: through Utah: Reconsiderations of Determinations at the Request of Claims Administrators 7/7/09 5/13/09 4/24/ Re Considerations 3/15/06 1/29/08 4/24/2012 Tennessee: Telephonic Peer to Peer Consultations 3/15/06 6/5/07 4/24/ Requests for Information and Notifications of Extension of Review Due Date 3/15/06 5/14/12 5/14/ Reimbursement for Duplication of Records 3/15/06 6/5/07 4/24/ Utilization Management Correspondence California: /15/06 5/1/08 4/24/2012 MasterList-2

48 3800 (cont) Massachusetts: Tennessee: Texas: Utah: Utilization Management Turn Around Times California: through Massachusetts: through Tennessee: Texas: through Utah: /15/06 6/14/11 4/24/ Quality Assurance Quality Control Quality Assurance Quality Control 3/15/06 6/9/08 4/24/ Utilization Management Business Hours Illinois: Massachusetts: Tennessee: Texas: Utah: /15/06 6/22/09 4/24/ Utilization Management In Business Hours Communications Access 3/15/06 5/1/08 4/24/2012 California: Utilization Management Communications Response 3/15/06 6/5/07 4/24/ Utilization Management After Hours Communications Access 3/15/06 6/9/08 4/24/ Utilization Management Communications Etiquette 3/15/06 6/5/07 4/24/ Marketing and Communications 3/15/06 3/14/11 4/24/ Utilization Management On Site Reviews 3/15/06 3/12/09 4/24/ Information Management 3/15/06 3/1/11 4/24/ Information Security Violations 3/1/11 3/1/11 4/24/ Client Procedures - State of California 6/5/2007 5/1/08 4/24/ Client Procedures State of Texas 3/12/09 3/12/09 4/24/2012 Master list revision: 4/27/2012 MasterList-3

49 Definitions CID Management Policy No Revision: 4.5 Revision Date:4/22/2012 Page 1 of 9 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes the definitions for general terminology used with utilization review at CID. This policy shall serve as the official reference for terms used within CID policies, documents, and communications. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /29/2008 Revised Revision /01/2008 Revised Revision /12/2009 Revised Revision /16/2009 Revised Revision /08/2010 Reviewed Revision /01/2011 Reviewed Revision /22/2011 Revised Revision /22/2012 Revised 3.0 Persons Affected This policy affects all employees and independent contractors who participate in performing utilization review at CID. 4.0 Policy The policy of CID Management is to require the use of appropriate terminology, on the part of the staff and independent contractors, during the performance of duties and responsibilities at CID. It is further the policy of CID management to ensure that the use of the following terms in any official CID documentation reflects the definitions of those terms as outlined in this policy. This policy is not intended to represent the vocabulary or terms of art of any specific state or jurisdiction

50 5.0 Definitions 5.1 ACOEM Practice Guidelines: American College of Occupational and Environmental Medicine s Occupational Medicine Practice Guidelines, Second Edition. 5.2 Adverse Determination: The denial, modification or delay of coverage for a treatment plan, including diagnosis or therapy. Texas: a determination, made through utilization review or retrospective review, that the health care services furnished or proposed to be furnished to an employee are not medically necessary or appropriate. 5.3 Appeal: Formal request for review or reconsideration of a CID determination 5.4 Appeals Consideration: Clinical review completed by appropriate clinical peer reviewers who were not involved in the original peer clinical review in which a decision not to certify a requested admission, procedure, or service has been appealed. 5.5 Approval: See certification 5.6 Attending Physician: The physician with primary responsibility for the care provided to a patient in a hospital or other health care facility 5.7 Authorization: See certification; for reviews conducted on California workers compensation claims, certification also includes assurance that appropriate reimbursement will be made for an approved specific course of proposed medical treatment 5.8 Board Certified: A certification approved by the American Board of Medical Specialties, the American Osteopathic Association, or other organization as accepted by URAC, that a physician has expertise in a particular specialty or field. 5.9 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 Case Management: A collaborative process which assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet an individual s health needs using communication and available resources to promote quality costeffective outcomes

51 5.11 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 Channeling: Directing care into a Preferred Provider Organization (PPO) or specialty network CID: Comprehensive Industrial Disability, Inc Claims Administrator: A self-administered workers' compensation insurer, a selfadministered self-insured employer, a self-administered legally uninsured employer, a self-administered joint powers authority, or a third-party claims administrator for an insurer, a self-insured employer, a legally uninsured employer or a joint powers authority. The claims administrator may utilize an agent to fulfill its utilization review responsibilities Client: A business or individual that purchases services from CID 5.16 Clinical Decision Support Tools: Protocols, guidelines, or algorithms that assist in the clinical decision-making process Clinical Director: A health professional who: (1) is duly licensed or certified; (2) is an employee of, or party to a contract with, an organization; and (3) who is responsible for clinical oversight of the utilization management program, including the credentialing of professional staff and quality assessment and improvement functions Clinical Peer: A physician or other health professional who holds an unrestricted license and is in the same or similar specialty as typically manages the medical condition, procedures, or treatment under review. Generally, as a peer in a similar specialty, the individual must be in the same profession, i.e., the same licensure category as the ordering provider. California: All such reviewers must be licensed by any State or the District of Columbia Clinical Rationale: A statement that provides additional clarification of the clinical basis for a determination. The clinical rationale should relate the determination to the patient s condition or treatment plan, and should supply a sufficient basis for a decision to pursue an appeal if appropriate Clinical Review Criteria: The written screens, decision rules, medical protocols, or guidelines used by the organization as an element in the evaluation of medical necessity and appropriateness of requested admissions, procedures, and services under the auspices of the applicable health benefit plan

52 5.21 Complainant: Texas: A person who files a complaint, as defined below. This could be an employee; an employer; a health care provider; or another person designated to act on behalf of an employee Complaint: Texas: any dissatisfaction expressed orally or in writing by a complainant to a network regarding any aspect of the network's operation. The term includes dissatisfaction relating to medical fee disputes and the network's administration and the manner in which a service is provided. The term does not include a misunderstanding or a problem of misinformation that is resolved promptly by clearing up the misunderstanding or supplying the appropriate information to the satisfaction of the complainant; or an oral or written expression of dissatisfaction or disagreement with an adverse determination Concurrent Review: The meaning of this term is subject to jurisdictional variance. California: Utilization management conducted during a patient s hospital stay or course of treatment. Sometimes called continued stay review. Massachusetts: A continuation of previously provided services, without a change in provider or diagnosis. Texas: During the course of treatment, including inpatient hospital stay; a review of on-going health care to determine if an extension of previously preauthorized health care is medically necessary Conditional non-certification: Administrative denial arising from lack of response to a written request for information; and following a determination by a clinical peer reviewer that the requested information was necessary to arrive at a determination of medical necessity Delay: Amendment of review due date to a date later than original due date. Arises from request for information or similar permitted/mandated process. California: See Conditional non-certification Denied: See non-certification 5.27 Emergency Health Care Services: Health care services for a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to place the patient's health in serious jeopardy Expedited Appeal: An appeal of a non-certification in a case involving urgent care or emergency health care Expedited Review: Utilization review conducted when the injured worker s condition is such that the injured worker faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other

53 major bodily function, or the normal timeframe for the decision-making process would be detrimental to the injured worker s life or health or could jeopardize the injured worker s permanent ability to regain maximum function Expert Reviewer: A physician, competent to evaluate the specific clinical issues involved in the medical treatment services and where these services are within the scope of the physician s practice, who has been consulted by the reviewing physician or utilization review medical director or utilization review clinical director to provide specialized review of medical information Facility Rendering Service: The institution or organization in or by which the requested admission, procedure, or service is provided. Such facilities may include, but are not limited to: hospitals; outpatient surgical facilities; individual practitioner offices; rehabilitation centers; residential treatment centers; skilled nursing facilities; laboratories; imaging centers; and other organizational providers of direct services to patients 5.32 First Level Review: See initial clinical review 5.33 Health Care Provider: A provider of medical services, as well as related services or goods, including but not limited to an individual provider or facility, a health care service plan, a health care organization, a member of a preferred provider organization or medical provider network as provided in Labor Code section Health Professional: An individual who: (1) has undergone formal training in a health care field; (2) holds an associate or higher degree in a health care field, or holds a state license or state certificate in a health care field; and (3) has professional experience in providing direct patient care Injured worker: an employee reporting information to an employer regarding an injury or illness occurring in relation to their employment 5.36 Initial Clinical Review: Clinical review conducted by appropriate licensed or certified health professionals. Initial clinical review staff may certify 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 License: A license or permit (or equivalent) to practice medicine or a health profession that is 1) issued by any state or jurisdiction in the United States; and 2) required for the performance of job functions Life-threatening: A disease or condition from which the likelihood of death is probable unless the course of the disease or condition is interrupted

54 5.39 Medical Director: A doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and who is an employee of, or party to a contract with, an organization, and who has responsibility for clinical oversight of the organization s utilization management, credentialing, quality management, and other clinical functions. Note: Specific jurisdictions may have additional requirements for Medical Director Medical Services: Services provided by a licensed health care professional. California: those goods and services provided pursuant to Article 2 (commencing with Labor Code section 4600) of Chapter 2 of Part 2 of Division 4 of the Labor Code Modified: A utilization management determination by which some services are certified and others are non-certified Non-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, does not meet the clinical requirements for medical necessity, appropriateness, level of care, or effectiveness under the auspices of the applicable health benefit plan Non-Clinical Administrative Staff: Staff who do not meet the definition of health professional Normal Turn Around Time: See Standard Turn Around Time Ordering Provider: The physician or other provider who specifically prescribes the health care service being reviewed Peer Clinical Review: Clinical review conducted by appropriate health professionals when a request for an admission, procedure, or service was not certified during initial clinical review Peer-to-Peer Conversation: A conversation conducted by telephone between a requesting provider and a peer reviewer. May be conducted prior to completion of determination, or subsequent to the rendering of a determination. If conducted subsequent to the rendering of a determination, such conversation shall not be considered a component of an appeal or reconsideration procedure and may not result in alteration or reversal of the original determination Physician Reviewer: See Clinical Peer 5.49 Pre-authorization: Texas: the process required to request approval from the insurance carrier or the network to provide a specific treatment or service before the treatment or service is provided

55 5.50 Pre-Certification Review: See prospective review 5.51 Pre-Review Screening: Automated or semi-automated screening of requests for authorization that may include: (1) collection of structured clinical data (including diagnosis, diagnosis codes, procedures, procedure codes); (2) asking scripted clinical questions; (3) accepting responses to scripted clinical questions; and (4) taking specific action (certification and assignment of length of stay explicitly linked to each of the possible responses). It excludes: (1) applying clinical judgment or interpretation; (2) accepting unstructured clinical information; (3) deviating from script; (4) engaging in unscripted clinical dialogue; (5) asking clinical follow-up questions; and (6) issuing non-certifications Principal Reason(s): A clinical or non-clinical statement describing the general reason(s) for the non-certification determination 5.53 Prior Authorization: See prospective review California: Any prior authorization process, including but not limited to, where authorization is provided without the submission of the request for authorization. (8CCR9792.7(a)(5)) 5.54 Prospective Review: Utilization management conducted prior to a patient s admission, stay, or other service or course of treatment (including outpatient procedures and services). Massachusetts: Utilization management conducted prior to a patient s admission, stay, or other service or course of treatment (including outpatient procedures and services), provided that the services under consideration have never previously been provided for the industrial injury. Texas: See Pre-authorization Provider: A licensed health care facility, program, agency, or health professional that delivers health care services Quality improvement project: An organization-wide initiative to measure and improve the service and/or care provided by the organization Quality Management (QM) program: A systematic data-driven effort to measure and improve consumer and client services and/or health care services

56 5.58 Re-considerations: Clinical review completed by appropriate clinical peer reviewer who completed an original peer clinical review in which a decision was made not to certify a requested admission, procedure, or service due to a lack of information from the provider. Texas: See Appeals Consideration Request For Authorization: A written confirmation of an oral request for a specific course of proposed medical treatment pursuant to Labor Code section 4610(h) or a written request for a specific course of proposed medical treatment. An oral request for authorization must be followed by a written confirmation of the request within seventy two (72) hours. Both the written confirmation of an oral request and the written request must be set forth in Form DLSR 5021, section 14006, or in the format required for Primary Treating Physician Progress Reports in subdivision (f) of section CCR Requesting Physician: The physician who has submitted the request for authorization Retrospective Review: Review conducted after services (including outpatient procedures and services) have been provided to the patient and for which services approval has not already been given. Retrospective review does not include subsequent review of services for which prospective or concurrent reviews for medical necessity and appropriateness were previously conducted. Texas: the process of reviewing the medical necessity and reasonableness of health care that has been provided to an injured employee Review of Service Request: Review of information submitted to the organization for health care services that do not need medical necessity certification nor result in a non-certification decision Rush: A request by the client to complete the utilization management process and reach a determination by midnight the following business day School: A grouping of practitioners as defined by their professional degree Second Level Review: See peer clinical review 5.66 Second Opinion: Requirement of some health plans to obtain an opinion about the medical necessity and appropriateness of specified proposed services by a practitioner other than the one originally making the recommendation Staff: The Organization s employees, including full-time employees, part-time employees, and consultants

57 5.68 Standard Appeal: An appeal of a non-certification that is not an expedited appeal. In most cases, standard appeals will not relate to cases involving urgent care. However, standard appeals may also include secondary appeals of expedited appeals Standard Turn Around Time: A request to complete the utilization management process and reach a determination within 2 business days following the receipt of all necessary medical information Stat: A request by the client to complete the utilization management process and reach a determination by midnight the same business day Structured Clinical Data: Clinical information that is precise and permits exact matching against explicit medical terms, diagnoses or procedure codes, or other explicit choices, without the need for interpretation Third Level Review: See appeals consideration 5.73 Utilization Management (UM): Evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefit plan Utilization Review Plan: California: the written plan filed with the Administrative Director pursuant to Labor Code section 4610, setting forth the policies and procedures, and a description of the utilization process. Texas: the screening criteria and utilization review procedures of an insurance carrier, a workers' compensation health care network, or a utilization review agent Utilization Review Process: [California] Utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, delay, or deny, based in whole or in part on medical necessity to cure or relieve, treatment recommendations by physicians, as defined in Labor Code section , prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Labor Code section Utilization review does not include determinations of the work-relatedness of injury or disease, or bill review for the purpose of determining whether the medical services were accurately billed. [Texas] A system for prospective or concurrent review of the medical necessity and appropriateness of health care services being provided or proposed to be provided to an individual in the state of Texas. The term does not include a review in response to an elective request for clarification of coverage or prepayment guarantee Worker: An ill or injured individual who is eligible for workers compensation benefits and who files for, or for whom a workers compensation claim has been filed

58 5.77 Written Notification: Includes a facsimile as well as communications in paper form. 6.0 Procedures Not applicable

59 Policy and Procedure Review and Update CID Management Policy No Revision: 3.1 Revision Date: 4/21/2009 Page 1 of 2 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which the CID Policies and Procedures manual is reviewed and revised no less than annually. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /21/2009 Revised Revision /08/2010 Reviewed Revision /26/2011 Reviewed Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects the senior management and department heads at CID responsible with policy review, revision, and approval duties. Additionally, this policy affects all staff whose jobs are impacted by revisions to the Policies and Procedures. 4.0 Policy 4.1 The policy of CID Management is to ensure that the corporation s policies and procedures are up-to-date and reflect best practices. As such, CID reviews all policies and procedures no less than annually and during impromptu meetings held as necessary when issues arise. 5.0 Definitions Definitions of terms are set forth in Policy Procedures

60 6.1 The Utilization Review Policies and Procedures Committee shall meet not less than annually to review, and revise as necessary, the Policies and Procedures manual. A scheduled yearly meeting for this purpose is held in mid-april. 6.2 Impromptu meetings of the Utilization Review Policies and Procedures Committee will be held as necessary when issues arise (e.g. changes in state laws, requests for change by clients, etc). 6.3 The Polices and Procedures manual will be reviewed by the Utilization Review Policies and Procedures Committee. This committee is comprised of the Medical Director; all Medical Directors associated with state-specific programs; the Clinical Director; the Director of Clinical Operations; the Director of Production; and a clinical reviewer. The UR Policies and Procedures Committee is charged with the following: Reviewing the existing CID utilization review policies and procedures for adherence with state and federal law Reviewing the existing CID utilization review policies and procedures for best practice performance Reviewing the existing CID corporation-wide policies and procedures for best practice performance, incorporating QI project recommendations when available To purpose, discuss, adopt, and implement changes to any and all existing CID utilization review policies and procedures as necessary. 6.4 All health care providers on the UR Policies and Procedures Committee are expected to provide substantive input. All content of the Policies and Procedures must be approved by the Medical Director. All Policies and Procedures that are components of a state-specific utilization review plan must also be approved by any state-specific Medical Director. 6.5 Changes, additions, and deletions, as well as newly drafted policies and procedures are posted to the CID intranet as well as announced via memo to all affected personnel.

61 Clinical Review Criteria CID Management Policy No Revision: 4.2 Revision Date: 4/21/2009 Page 1 of 19 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which the Clinical Review Criteria Committee shall select the clinical review criteria that shall be used in the performance of utilization management at CID. This policy establishes guidelines by which the clinical review criteria shall be communicated to the health professionals, including initial clinical reviewers, expert reviewers, and clinical peers, who perform functions within the scope of utilization management in the employment of, on contracting with, CID. This policy establishes guidelines by which the QAQC Committee shall monitor the application of the clinical review criteria in the performance of utilization management operations. 2.0 Revision History Revision /15/2006 New Policy and Addenda/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /29/2008 Revised Revision /21/2009 Revised Revision /08/2010 Reviewed Revision /01/2011 Reviewed Revision /22/2011 Reviewed Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all health professionals, including initial clinical reviewers, expert reviewers, and clinical peers, performing functions within the scope of utilization management in the employment of, or contracting with, CID. 4.0 Policy

62 The policy of CID Management is to ensure that the clinical review criteria used within utilization management operations at CID be evidence-based and reflect best-practice care. The clinical review criteria shall be evaluated no less than once per year by the Clinical Review Criteria Committee and shall be modified, updated or replaced as deemed necessary and appropriate by said committee. The application of the clinical review criteria by the health professionals, including initial clinical reviewers, expert reviewers, and clinical peers, performing functions within the scope of utilization management in the employment of, or contracting with, CID, shall be monitored by the QAQC Committee. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 Membership of the Clinical Review Criteria Committee shall include, at minimum, the Medical Director; the Medical Director of any state-specific utilization review program; the Clinical Director; the Clinical Operations Director; an initial clinical reviewer; a clinical peer reviewer; and a QAQC reviewer. 6.2 The Clinical Review Criteria Committee shall meet not less than annually to review the clinical review criteria currently used in CID s utilization management operations. 6.3 The Clinical Review Criteria Committee shall meet not less than annually to discuss the addition, deletion, or modification of clinical review criteria used in CID s utilization management operations. 6.4 The Clinical Review Criteria Committee shall ensure that the clinical review criteria approved for use within CID s utilization management operations meet the following standards: The clinical review criteria are evidence based The clinical review criteria were developed with input from providers involved in full time medical practice The clinical review criteria are nationally recognized and are based on scientific medical evidence. 6.5 The Clinical Review Criteria Committee shall charge the Clinical Director with communicating the selected clinical review criteria to all health professionals, including initial clinical reviewers, expert reviewers, and clinical peers, who perform functions within the scope of utilization management in the employment of, on contracting with, CID

63 6.6 The Clinical Review Criteria Committee shall charge the Clinical Director with ensuring that all the health professionals, including initial clinical reviewers, expert reviewers, clinical peers, and quality assurance/quality control reviewers, who perform functions within the scope of utilization management in the employment of, on contracting with, CID, have access to the selected clinical review criteria. 6.7 The QAQC Committee shall monitor the utilization review determinations of all health professionals, including initial clinical reviewers, expert reviewers, and clinical peers, who perform functions within the scope of utilization management in the employment of, on contracting with, CID, to ensure adherence to the clinical review criteria. 6.8 The QAQC Committee shall impose corrective action for all health professionals, including initial clinical reviewers, expert reviewers, and clinical peers, who perform functions within the scope of utilization management in the employment of, on contracting with, CID, and who have not adhered to the clinical review criteria. 6.9 The CID clinical review criteria currently in place for utilization management includes: American College of Occupational and Environmental Medicine s Occupational Medicine Practice Guidelines, 2 nd ed published by OEM Press, Beverly Farms, MA The Official Disability Guidelines published by Work Loss Data Institute, Encinitas, CA The National Guidelines Clearinghouse, an initiative of the Agency of Health Care Research and Quality, U.S. Department of Health and Human Services. This source is not a guideline per se, but a collection of guidelines that have been evaluated and summarized by the U.S. DHHS. When used as review criteria, reviewers will cite the original source guideline National Institute of Health s PubMed scientific literature database. This source is not a guideline per se, but a library of peer-reviewed health sciences publications. When used as review criteria, reviewers will cite the original source publication. Articles cited must be the most recent and/or best-quality research on the medical service under review; and must be a randomized clinical trial or better. This source should not be used by reviewers unless there are no other applicable review criteria available

64 6.9.5 The State of California 8 CCR Medical Treatment Utilization Schedule. onschedule/mtus_finalregulations.pdf Department of Industrial Accidents Health Care Services Board Treatment Guidelines, Commonwealth of Massachusetts Colorado Department of Labor and Employment Medical Treatment Guidelines CID Internal Guideline #1: Medical Goods and Services for which No Acceptable Scientific Evidence Exists This criteria may only be used for authorization; and only with prior approval of CID senior clinical staff Delaware Health Care Services Guidelines Minnesota Department of Labor and Industry Washington State Department of Labor and Industries, Medical Treatment Guidelines Wyoming Workers Safety and Compensation Division Treatment Guidelines

65 CID Management Clinical Review Criteria Description ACOEM Guidelines American College of Occupational and Environmental Medicine s Occupational Medicine Practice Guidelines, 2 nd ed published by OEM Press, Beverly Farms, MA. Description: ACOEM guidelines are a set of treatment guidelines applicable to acute musculoskeletal injuries; injuries of the eye; chronic pain; and stress related conditions. How were the criteria developed: According to ACEOM, as the American College of Occupational and Environmental Medicine (ACOEM) prepared to begin the process of review and revision of the first edition material, medical societies representing virtually all specialties involved in occupational medicine were invited to appoint one or more of their members to assist ACOEM in updating the guidelines. Consequently, the guidelines in this volume represent the current, collective voice of health care professionals across the spectrum of specialists who treat work-related injuries and occupational diseases. The individual representatives of the various specialty societies and the independent reviewers involved in the process of updating this edition are listed in the Acknowledgments. Who was involved in the development of the criteria: According to ACOEM, the following people were involved in the development of the criteria: Jeffrey S. Harris, MD, MPH, MBA, FACOEM Bernard R. Blais, MD, FACOEM, FAAO, FACS Julia E. Klees, MD, MPH, FACOEM Elizabeth Genovese, MD, MBA, FAADEP Michael N. Goertz, MD, MPH, FACOEM Lee S. Glass, MD Julia E. Klees, MD, MPH, FACOEM Michael N. Goertz, MD, MPH, FACOEM Harold E. Hoffman, MD, CCFP, FACOEM, FRCPC C. David Rowlett, MD, MS Jennifer H. Christian, MD, MPH, FACPM Philip I. Harber, MD, MPH, FACOEM, FCCP John P. Holland, MD, MPH, FACOEM Kathryn L. Mueller, MD, MPH, FACEP, FACOEM Douglas J. Patron, MD, MSPH Bernyce M. Peplowski, DO, MS Jack Richman, MD, CCFP, DOHS, FACOEM Timothy J. Key, MD, MPH, FACOEM Edward A. Emmett, MD, MS, FACOEM C. Donald Williams, MD, CGP Edwin Klimek, MD M. Bowes Hamill, MD, FAAO Jonathan S. Halperin, MD

66 Michael Saffir, MD Hillel M. Sommer, MD, FRCPC, FAAPMR Kevin C. Chung, MD, MS, FACS M. Felix Freshwater, MD Nash Naam, MD, FACS, FICS Mary Lou Wassel, MEd, RN, COHN-S/CM, ARM Alan L. Colledge, MD Raymond G. Hart, MD, MPH, FACEP William C. Dalsey, MD, MBA, FACEP David Rubin, MD Jeffrey L. Weaver, OD, MS, MBA, FAAO Tim Pinsky, DO, MPH, FACOEM, FAOCOPM, FAADEP Jill Galper, PT, MEd Pamela Colman, DPM David M. Schofield, DPM, FCFO James R. Callan, PhD, FAPA Michael E. Geisser, PhD Dennis C. Harper, PhD, FAACP, FAPA, FAACPDM David P. Martin, MD, PhD Craig H. Johnson, MD Maura D. Iversen, ScD, MPH, PT Phillip McClure, PhD, PT Carol A. Oatis, PhD, PT Ewa Roos, PT, PhD Cheryl Riegger-Krugh, ScD, PT Robert Mootz, DC, FICC, FABS Herbert I. Machleder, MD, FACS Albert J. Osbahr, MD, FAAFP, FACOEM Thomas J. Tredici, MD, FAAO John M. Williams, Sr., MD, MPH, FAAO Edward G. Zurad, MD, FAAFP, MACOEM How often will they be updated by developing group: Not addressed within the guidelines

67 CID Management Clinical Review Criteria Description Official Disability Guidelines The Official Disability Guidelines published by Work Loss Data Institute, Encinitas, CA. Description: The ODG is a comprehensive set of treatment guidelines for both acute and chronic conditions. How were the criteria developed: According to the ODG preface, the Official Disability Guidelines (ODG) links together four U.S. government databases to provide length-of-disability experience data that can be used to manage employee productivity. These four databases are the following: ICD-9-CM The International Classification of Diseases, 9th Revision, Clinical Modification. This is the principle coding system used worldwide for the diagnosis of any medical condition. The main section of ODG includes verbatim the complete "Volume 1, Diseases: Tabular List" of the current Official ICD-9-CM publication. CDC NCHS NHIS The National Health Interview Survey (NHIS) is conducted annually by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC). ODG uses data from every year beginning in 1987 until the most current. OSHA BLS OII The Bureau of Labor Statistics (BLS) reports annually on Occupational Injuries and Illnesses (OII) from forms submitted by employers to the Occupational Safety and Health Administration (OSHA). ODG uses data from the latest available year. HCUP The Healthcare Cost and Utilization Project (HCUP) is a family of health care databases and related software tools and products developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality (AHRQ) to create a national information resource of patient-level health care data. HCUP includes the largest collection of longitudinal medical care data in the United States. These databases enable research on a broad range of health policy issues, including cost and quality of health services, medical practice patterns, access to health care programs, and outcomes of treatments at the national, State, and local market levels. The latest available year is included in ODG. From the beginning, the first edition of Official Disability Guidelines (ODG) in 1996 provided lost time guidelines using actual experience data from these federal government databases, specifically OSHA BLS (Occupational Safety and Health Administration Bureau of Labor Statistics) and CDC NCHS NHIS (Centers for Disease Control and Prevention, National Center for Health Statistics, National Health Interview Survey). The raw data is presented graphically so users can compare it directly with their own experience, and it is designed to enhance a timely and appropriate return-to-work for workers suffering from illness or injury. From the beginning, ODG was based on actual experience, not expert opinion. This made ODG fair to employees and defensible by employers. With changes to the Federal Rules of Evidence, the ODG

68 guidelines also became the most likely to stand up in court. As a result of recent U.S. Supreme Court decisions, the Federal Rules of Evidence were recently amended in December The new rules state that statistical studies will be admissible under the Federal Rules of Evidence, and that such methods generally satisfy important aspects of the scientific knowledge requirement articulated in the Daubert Decision. Furthermore, it states that courts have described surveys as the most direct form of evidence that can be offered, and several courts have drawn negative inferences from the absence of a survey. Who was involved in the development of the criteria: The ODG editorial advisory board includes: Charles W. Kennedy, Jr., MD John C. Agee, DO Mary C. Amann, MS, RN, COHN-S Robert N. Anfield, MD, JD Robert A. Barlow, Jr., MD, MPH Robert J. Barth, Ph.D. Melissa Bean, DO, MBA, MPH James Becker, MD Faiyaz A. Bhojani, MD, MPH Timothy Bialecki, DC Stanley J. Bigos, MD Susan G. Blitz, MD, MPH H. F. Bonfili, MD, MPH David H. Brill, MD, MA, MPH Roy C. Brown, MD, MPH Paul J. Brownson, MD Mary Capelli-Schellpfeffer, MD, MPA Pieter Coetzer, MBChB MSc FAADEP CIME Richard Cohen, MD, MPH Alan Colledge, MD, FAADEP, CIME Alberto M. Colombi, MD James P. Crossan, MD Steve Demeter, MD, MPH Deborah V. DiBenedetto, MBA RN COHN-S/CM ABDA Dennis DiGiorgi, DC, CCIC, DABQAURP James J. Edwards, Jr., MD Dennis G. Egnatz, MD Michael Erdil, MD, FACOEM Preston Fitzgerald, Sr. DC Joseph A. Fortuna, MD Gary C. Freeman, MD, JD Bob Gant, PhD Diane Green, Annette B. Haag, MA, RN, COHN-S/CM Constance R. Hanna, MD Paul D. Harris, MD, MPH

69 T. Warner Hudson III, MD FACOEM FAADEP Fikry W. Isaac, MD, MPH Stephen G. Jacobson, MD Gregory Jewell, MD, MS Pamella D. Johnston-Thomas, MD, MPH Christine M. Kalina, MBA MS RN FAAOHN COHN-S/CM Charles W. Kennedy, Jr., MD Gary M. Kohn, MD Ann Kuhnen, MD Ivan Lockyer, B Comm MBChB FAADEP David J. Louis, MD, MS Lloyd J. Luke, MD Michael G. Maroldo, MD True Martin, MD, FAADEP Douglas W. Martin, MD FAADEP FACOEM FAAFP Edward G. Mauceri, MD George R. Mc Govern, MD, AB David K. McKenas, MD, MPH J. Mark Melhorn, MD FAAOS FAADEP FACS Michael A. Meschke, MD Laurence A. Miller, MD Dana B. Mirkin, MD Joseph Monkofsky, Jr., MD, MPH Vert Mooney, MD Richard H. Nachtigall, MD Wrendell R. Nealy, Sr., MD Chet Nierenberg, MD Mark C. Olesen, MD, MPH Stuart H. Platt, MSPT, PT Charles Prezzia, MD, MPH Dave Randolph, MD, MPH, FAADEP James K. Ross, MD, MBA E. Alannah Ruder, MD Les Ruthven, Ph.D. Steven Schneider, MD Joseph J. Schwerha, MD, MPH Russell Travis, MD Eugene A. Truchelut, MD C.P. Wen, MD John J. Williams, RN, COHN-S How often will they be updated by developing group: Updates are done as necessary to the website, which may be as frequent as monthly, but will occur no less than 1 time per year

70 CID Management Clinical Review Criteria Description National Guidelines Clearinghouse The National Guidelines Clearinghouse, an initiative of the Agency of Health Care Research and Quality, U.S. Department of Health and Human Services. Description: The National Guideline Clearinghouse (NGC) is a comprehensive database of evidence-based clinical practice guidelines and related documents. NGC is an initiative of the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. NGC was originally created by AHRQ in partnership with the American Medical Association and the American Association of Health Plans (now America's Health Insurance Plans [AHIP]). The NGC mission is to provide physicians, nurses, and other health professionals, health care providers, health plans, integrated delivery systems, purchasers and others an accessible mechanism for obtaining objective, detailed information on clinical practice guidelines and to further their dissemination, implementation and use. Key components of NGC include: Structured abstracts (summaries) about the guideline and its development Links to full-text guidelines, where available, and/or ordering information for print copies Palm-based PDA Downloads of the Complete NGC Summary for all guidelines represented in the database. A Guideline Comparison utility that gives users the ability to generate side-by-side comparisons for any combination of two or more guidelines Unique guideline comparisons called Guideline Syntheses prepared by NGC staff, compare guidelines covering similar topics, highlighting areas of similarity and difference. NGC Guideline Syntheses often provide a comparison of guidelines developed in different countries, providing insight into commonalities and differences in international health practices. An electronic forum, NGC-L for exchanging information on clinical practice guidelines, their development, implementation and use An Annotated Bibliography database where users can search for citations for publications and resources about guidelines, including guideline development and methodology, structure, evaluation, and implementation Other user-friendly features include the following: What's New enables users to see what guidelines have been added each week and includes an index of all guidelines in NGC. NGC Update Service is a weekly electronic mailing of new and updated guidelines posted to the NGC Web site. Detailed Search enables users to create very specific search queries based on the various attributes found in the NGC Classification Scheme

71 NGC Browse permits users to scan for guidelines available on the NGC site by disease/condition, treatment/intervention, or developing organization. PDA/Palm List provides users with information regarding the availability of full-text guidelines and/or companion documents available through the guideline developer, that can be downloaded for the handheld computer (Personal Digital Assistant [PDA], Palm, etc.). AHRQ Evidence Reports/Technical Assessments list provides users with links to the Summaries and Full-Text Reports for evidence reports and technology assessments produced under the Agency for Healthcare Research and Quality (AHRQ) Evidencebased Practice Center (EPC) Program. Access the list of EPC Reports, with links to summaries and/or full-text publications. Glossary provides definitions of terms used in the standardized abstracts (summaries). How were the criteria developed: The guidelines may be developed by any agency or organization. The NCG determines which guidelines meet their criteria before posting them to the site. Who was involved in the development of the criteria: The guidelines may be developed by any agency or organization. Each guideline must be evaluated on it s own. How often will they be updated by developing group: Each guideline developer determines how often the guidelines will be updated

72 CID Management Clinical Review Criteria Description NIH PubMed National Institute of Health s PubMed scientific literature database. Description: PubMed, available via the NCBI Entrez retrieval system, was developed by the National Center for Biotechnology Information (NCBI) at the National Library of Medicine (NLM), located at the National Institutes of Health (NIH). Entrez is the text-based search and retrieval system used at NCBI for services including PubMed, Nucleotide and Protein Sequences, Protein Structures, Complete Genomes, Taxonomy, OMIM, and many others. PubMed was designed to provide access to citations from biomedical literature. LinkOut provides access to full-text articles at journal Web sites and other related Web resources. PubMed also provides access and links to the other Entrez molecular biology resources. Publishers participating in PubMed electronically submit their citations to NCBI prior to or at the time of publication. If the publisher has a web site that offers full-text of its journals, PubMed provides links to that site as well as biological resources, consumer health information, research tools, and more. There may be a charge to access the text or information. In addition, PubMed provides a Batch Citation Matcher, which allows users to match their citations to PubMed citations using bibliographic information such as journal, volume, issue, page number, and year. PubMed Coverage - PubMed provides access to bibliographic information that includes MEDLINE, OLDMEDLINE, as well as: o The out-of-scope citations (e.g., articles on plate tectonics or astrophysics) from certain MEDLINE journals, primarily general science and chemistry journals, for which the life sciences articles are indexed for MEDLINE. o Citations that precede the date that a journal was selected for MEDLINE indexing. o Some additional life science journals that submit full text to PubMedCentral and receive a qualitative review by NLM. How were the criteria developed: Criteria are developed through scientific process. Prior to publication, each is subject to peer review. Who was involved in the development of the criteria: Each criteria is developed by a separate entity or provider. How often will they be updated by developing group: Normally these are not updated as they are results of research processes

73 CID Management Clinical Review Criteria Description State of California 8CCR Medical Treatment Utilization Schedule The State of California 8 CCR Medical Treatment Utilization Schedule. nalregulations.pdf Description: The Administrative Director of the Division of Workers Compensation, pursuant to the authority granted by Labor Code sections 59, 133, , and , has adopted Article of Chapter 4.5, Subchapter 1, Division 1, of Title 8, California Code of Regulations, Section Medical Treatment Utilization Schedule. How were the criteria developed: CA Labor Code states: On or before December 1, 2004, the administrative director, in consultation with the Commission on Health and Safety and Workers' Compensation, shall adopt, after public hearings, a medical treatment utilization schedule, that shall incorporate the evidence-based, peer-reviewed, nationally recognized standards of care recommended by the commission pursuant to Section 77.5, and that shall address, at a minimum, the frequency, duration, intensity, and appropriateness of all treatment procedures and modalities commonly performed in workers' compensation cases. CA Labor Code (b) states: (b) The recommended guidelines set forth in the schedule adopted pursuant to subdivision (a) shall reflect practices that are evidence and scientifically based, nationally recognized, and peer-reviewed. The guidelines shall be designed to assist providers by offering an analytical framework for the evaluation and treatment of injured workers, and shall constitute care in accordance with Section 4600 for all injured workers diagnosed with industrial conditions. CA Labor Code 4610(f) states: The criteria or guidelines used in the utilization review process to determine whether to approve, modify, delay, or deny medical treatment services shall be all of the following: (1) Developed with involvement from actively practicing physicians. (2) Consistent with the schedule for medical treatment utilization adopted pursuant to Section Prior to adoption of the schedule, these policies and procedures shall be consistent with the recommended standards set forth in the American College of Occupational and Environmental Medicine Occupational Medical PracticeGuidelines. Who was involved in the development of the criteria: The State of California has not published a list of the contributors. How often will they be updated by developing group: CA Labor Code 4610 (f) requires criteria to be evaluated at least annually and updated as necessary

74 CID Management Clinical Review Criteria Description Commonwealth of Massachusetts HCSB Treatment Guidelines. Department of Industrial Accidents Health Care Services Board Treatment Guidelines, Commonwealth of Massachusetts. Description: Treatment guidelines or practice algorithms are part of a new direction in health care policy and are considered optimal strategies for patient management around which practice patterns should converge. These treatment guidelines are meant to cover the majority of tests and treatments for each condition for which they apply. The original guidelines were derived from multiple sources including, but not limited to, the American Academy of Orthopedic Surgeons, the state of Washington, Department of Labor and Industries and multi-disciplinary committees of the Health Care Services Board. How were the criteria developed: In 1991, MA Governor William Weld promulgated major Workers' Compensation reform legislation. The legislation provided a new direction for Workers' Compensation health care in Massachusetts's. Central to the reform was the Department of Industrial Accidents' (DIA) implementation of a utilization review and quality assessment program to monitor the appropriateness of medical services, as well as the necessity and the effectiveness of treatment for injured/ill employees. Further, the statute reconvened and enhanced the responsibilities of the Health Care Services Board (HCSB). Composed of 13 voluntary members, one of the responsibilities the Board was charged with was the development of treatment guidelines for the appropriate and necessary treatment of Massachusetts's injured/ill workers. These treatment guidelines were accepted and per statute M.G.L. c. 152 promulgated on July 1, 1993, to be used for all health care services rendered on or after October 1, Who was involved in the development of the criteria: According to the MA State website, the committee who developed the criteria consisted of 13 voluntary members. The names of the members were not noted. How often will they be updated by developing group: M.G.L. c. 152 requires annual review of the guidelines currently in existence

75 CID Management Clinical Review Criteria Description Colorado Medical Treatment Guidelines Colorado Department of Labor and Employment Medical Treatment Guidelines. Description: According to the Colorado Division of Workers Compensation, in an effort to comply with its legislative charge to assure appropriate medical care at a reasonable cost, the director of the Division has promulgated these "Medical Treatment Guidelines." This rule provides a system of evaluation and treatment guidelines for high cost or high frequency categories of occupational injury or disease to assure appropriate medical care at a reasonable cost. How were the criteria developed: The Colorado Department of Labor and Employment has not published the process by which the criteria were developed. Who was involved in the development of the criteria: The Colorado Department of Labor and Employment has not published a list of the contributors. How often will they be updated by developing group: Pursuant to section (3)(a)(I), C.R.S., prior to July 1 of each year the Division Director shall review all medical treatment guidelines. Written comments which have been submitted by the public to the director or the Division's medical director will be considered during such reviews

76 CID Management Clinical Review Criteria Description Delaware Health Care Practices Guidelines Delaware Health Care Practices Guidelines Description: Pursuant to 19 Del.C. 2322C, health care practice guidelines have been adopted and recommended by the Health Care Advisory Panel to guide utilization of health care treatments in workers' compensation including, but not limited to, care provided for the treatment of employees by or under the supervision of a licensed health care provider, prescription drug utilization, inpatient hospitalization and length of stay, diagnostic testing, physical therapy, chiropractic care and palliative care. How were the criteria developed: The Delaware Department of Labor has not published the process by which the criteria were developed. Who was involved in the development of the criteria: Bruce Rudin, M.D. Chair George B. Heckler, Esquire, Vice-Chair Marcia Dewitt Walter Power, M.D. Glenn Brown Josette Covington, M.D. James Downing, M.D. Barry Bakst, D.O. Richard Heffron Wayne Collison Douglas Briggs, D.C How often will they be updated by developing group: The Delaware Department of Labor has not published a schedule of review or revision

77 CID Management Clinical Review Criteria Description Minnesota Department of Labor and Industry Minnesota Department of Labor and Industry Description: Guidelines developed by the Minnesota Department of Labor and Industry in the form of regulatory language, in an attempt to define what is medically necessary. How were the criteria developed: The Minnesota Department of Labor and Industry has not published the process by which the criteria were developed. Who was involved in the development of the criteria: Philip Bachman, M.D. Beth Baker, M.D., MSRB chairperson Barbara Baum, M.S., P.T. Jeffrey Bonsell, D.C. Michael Goertz, M.D. Andrea Trimble Hart, CPCU Kathi Henrickson, R.N. Gregory J. Hynan, D.C. John Kipp, M.D., J.D. Reed Pollack Andrew Schmidt, M.D. Elizabeth Shogren, R.N. Jon Talsness, M.D. How often will they be updated by developing group: The Minnesota Department of Labor and Industry has not published a schedule of review or revision

78 CID Management Clinical Review Criteria Description Washington State Department of Labor and Industries, Medical Treatment Guidelines Washington State Department of Labor and Industries, Medical Treatment Guidelines Description: How were the criteria developed: The Washington State Department of Labor and Industries, Medical Treatment Guidelines have been developed by the Office of the Medical Director in collaboration with practicing physicians and advisors. This is believed to be the Industrial Insurance Medical Advisory Committee. Who was involved in the development of the criteria: Ruth M. Bishop, DO Gregory T. Carter, MD Dianna Chamblin, MD (Vice-chair) G. A. DeAndrea, MD, MBA Jordan Firestone, MD, PhD, MPH Andrew Friedman, MD Kirk T. Harmon, MD Walter F. Krengel III, MD Robert G. R. Lang, MD (Chair) Janet E. Ploss, MD Mark Sullivan, MD, PhD David J. Tauben, MD G. Robert Waring, MD Gerald N. Yorioka, MD How often will they be updated by developing group: The Washington State Department of Labor and Industries has not published a schedule of review or revision

79 CID Management Clinical Review Criteria Description Wyoming Workers Safety and Compensation Division Treatment Guidelines Wyoming Workers Safety and Compensation Division Treatment Guidelines Description: None provided by jurisdictional authority How were the criteria developed: Consensus development will take place between the Medical Commission members and active practicing community-based Heath Care Providers who are clinical experts in the topic(s) to be addressed. Newly developed treatment guidelines may be quite liberally contructed, however, subsequent tightening of the treatment guidelines would occur as national guidelines are set, or other scientific evidence becomes available. Who was involved in the development of the criteria: Unknown How often will they be updated by developing group: The Wyoming Workers Safety and Compensation Division has not published a schedule of review or revision

80 Conflict of Interest CID Management Policy No Revision: 3.0 Revision Date: 6/5/2007 Page 1 of 2 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines addressing conflicts of interest that may arise in the performance of utilization management. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /14/09 Reviewed Revision /08/2010 Reviewed Revision /27/2011 Reviewed Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all CID employees and contractors who participate in any utilization management operations. 4.0 Policy The policy of CID Management is to avoid any conflicts of interest which may arise in the performance of utilization management operations. Conflicts of interest may include, but are not limited to: 4.1 an ownership interest of greater than 5% between affected parties 4.2 a material professional or business relationship 4.3 a direct or indirect financial incentive for a particular determination 4.4 incentives to promote the use of a certain product or service 4.5 a known familial relationship

81 4.6 any prior involvement in the specific case under review 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 Each CID employee and contractor shall sign a contract stating that they shall not perform utilization management services in situations where a conflict of interest exists. 6.2 Each CID employee and contractor shall be trained on recognizing conflict of interest situations. 6.3 If, in the performance of utilization management duties, any CID non-clinical administrative staff member discovers that they have a conflict of interest, they shall immediately cease activity and notify their direct supervisor. 6.4 The supervisor shall then re-assign the work duties to an alternate CID non-clinical administrative staff member for whom no conflict of interest exists. 6.5 The supervisor shall record the conflict of interest, and the re-assignment of work duties, within the CID system. 6.6 If, in the performance of utilization management duties, any initial clinical reviewer or clinical peer reviewer contracted with CID discovers that they have a conflict of interest, they shall immediately recuse themselves from the review using the CID system. 6.7 The CID system shall re-assign the work duties to an alternate initial clinical reviewer or clinical peer reviewer for whom no conflict of interest has been identified. 6.8 The CID system shall record the conflict of interest, and the re-assignment of work duties, as an activity within the CID system. 6.9 To avoid conflict of interest situations, CID specifically does not have a system for reimbursement, bonuses, or incentives to staff based directly or indirectly on consumer utilization of health care services

82 Utilization Management Labor Code and Regulations Compliance CID Management Policy No Revision: 3.0 Revision Date: 6/5/07 Page 1 of 58 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which CID ensures that it remains compliant with labor code and regulations, including URAC Standards, addressing the performance of utilization management operations. 2.0 Revision History Revision /15/2006 New Policy and Addenda/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /26/2011 Reviewed Revision /22/2011 Reviewed Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects the Medical Director, Clinical Director and any parties or committees that may be required to convene as a result of changes to the labor code or regulations. 4.0 Policy The policy of CID Management is to monitor the labor code and regulations, including URAC Standards, addressing utilization management on an ongoing basis to ensure the CID utilization management policies and procedures remain in compliance. 5.0 Definitions Definitions of terms are set forth in Policy Procedures

83 6.1 On an ongoing basis, the Medical Director and Clinical Director shall monitor the utilization management labor codes and regulations in each state in which CID performs utilization management functions. 6.2 On an ongoing basis, the Clinical Director shall monitor for changes in URAC Standards for current compliance. Additionally, the Clinical Director will check with URAC for updates to the Standards by contacting URAC by phone at (202) and check on the website under the link News Room and sub-link Latest News Releases for updates or revision to the URAC Standards. 6.3 If an update is made to either labor codes or regulations surrounding utilization management, the Medical Director and Clinical Director shall notify any CID parties and/or committees that must be convened to address the new labor code and/or regulations. 6.4 The CID parties and/or committees shall review the current policies and procedures and make any necessary modifications to ensure CID s continued compliance with labor code and regulations. 6.5 The CID parties and/or committees shall report their actions to the Medical Director and Clinical Director. 6.6 The Medical Director shall review the final modifications to the CID policies and/or procedures and ensure that CID remains in compliance with labor code and regulations surrounding utilization management

84 Addenda California Labor Code and Regulations (a) Upon adoption by the administrative director of a medical treatment utilization schedule pursuant to Section , the recommended guidelines set forth in the schedule shall be presumptively correct on the issue of extent and scope of medical treatment. The presumption is rebuttable and may be controverted by a preponderance of the scientific medical evidence establishing that a variance from the guidelines is reasonably required to cure or relieve the injured worker from the effects of his or her injury. The presumption created is one affecting the burden of proof. (b) The recommended guidelines set forth in the schedule adopted pursuant to subdivision (a) shall reflect practices that are evidence and scientifically based, nationally recognized, and peerreviewed. The guidelines shall be designed to assist providers by offering an analytical framework for the evaluation and treatment of injured workers, and shall constitute care in accordance with Section 4600 for all injured workers diagnosed with industrial conditions. (c) Three months after the publication date of the updated American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines, and continuing until the effective date of a medical treatment utilization schedule, pursuant to Section , the recommended guidelines set forth in the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines shall be presumptively correct on the issue of extent and scope of medical treatment, regardless of date of injury. The presumption is rebuttable and may be controverted by a preponderance of the evidence establishing that a variance from the guidelines is reasonably required to cure and relieve the employee from the effects of his or her injury, in accordance with Section The presumption created is one affecting the burden of proof. (d) (1) Notwithstanding the medical treatment utilization schedule or the guidelines set forth in the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines, for injuries occurring on and after January 1, 2004, an employee shall be entitled to no more than 24 chiropractic, 24 occupational therapy, and 24 physical therapy visits per industrial injury. (2) This subdivision shall not apply when an employer authorizes, in writing, additional visits to a health care practitioner for physical medicine services. (3) Paragraph (1) shall not apply to visits for postsurgical physical medicine and postsurgical rehabilitation services provided in compliance with a postsurgical treatment utilization schedule established by the administrative director pursuant to Section (e) For all injuries not covered by the American College of Occupational and Environmental Medicine's Occupational Medicine Practice Guidelines or official utilization schedule after

85 adoption pursuant to Section , authorized treatment shall be in accordance with other evidence based medical treatment guidelines generally recognized by the national medical community and that are scientifically based. LC (a) For purposes of this section, "utilization review" means utilization review or utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, delay, or deny, based in whole or in part on medical necessity to cure and relieve, treatment recommendations by physicians, as defined in Section , prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Section (b) Every employer shall establish a utilization review process in compliance with this section, either directly or through its insurer or an entity with which an employer or insurer contracts for these services. (c) Each utilization review process shall be governed by written policies and procedures. These policies and procedures shall ensure that decisions based on the medical necessity to cure and relieve of proposed medical treatment services are consistent with the schedule for medical treatment utilization adopted pursuant to Section Prior to adoption of the schedule, these policies and procedures shall be consistent with the recommended standards set forth in the American College of Occupational and Environmental Medicine Occupational Medical Practice Guidelines. These policies and procedures, and a description of the utilization process, shall be filed with the administrative director and shall be disclosed by the employer to employees, physicians, and the public upon request. (d) If an employer, insurer, or other entity subject to this section requests medical information from a physician in order to determine whether to approve, modify, delay, or deny requests for authorization, the employer shall request only the information reasonably necessary to make the determination. The employer, insurer, or other entity shall employ or designate a medical director who holds an unrestricted license to practice medicine in this state issued pursuant to Section 2050 or Section 2450 of the Business and Professions Code. The medical director shall ensure that the process by which the employer or other entity reviews and approves, modifies, delays, or denies requests by physicians prior to, retrospectively, or concurrent with the provision of medical treatment services, complies with the requirements of this section. Nothing in this section shall be construed as restricting the existing authority of the Medical Board of California. (e) No person other than a licensed physician who is competent to evaluate the specific clinical issues involved in the medical treatment services, and where these services are within the scope of the physician's practice, requested by the physician may modify, delay, or deny requests for authorization of medical treatment for reasons of medical necessity to cure and relieve. (f) The criteria or guidelines used in the utilization review process to determine whether to approve, modify, delay, or deny medical treatment services shall be all of the following:

86 (1) Developed with involvement from actively practicing physicians. (2) Consistent with the schedule for medical treatment utilization adopted pursuant to Section Prior to adoption of the schedule, these policies and procedures shall be consistent with the recommended standards set forth in the American College of Occupational and Environmental Medicine Occupational Medical Practice Guidelines. (3) Evaluated at least annually, and updated if necessary. (4) Disclosed to the physician and the employee, if used as the basis of a decision to modify, delay, or deny services in a specified case under review. (5) Available to the public upon request. An employer shall only be required to disclose the criteria or guidelines for the specific procedures or conditions requested. An employer may charge members of the public reasonable copying and postage expenses related to disclosing criteria or guidelines pursuant to this paragraph. Criteria or guidelines may also be made available through electronic means. No charge shall be required for an employee whose physician's request for medical treatment services is under review. (g) In determining whether to approve, modify, delay, or deny requests by physicians prior to, retrospectively, or concurrent with the provisions of medical treatment services to employees all of the following requirements must be met: (1) Prospective or concurrent decisions shall be made in a timely fashion that is appropriate for the nature of the employee's condition, not to exceed five working days from the receipt of the information reasonably necessary to make the determination, but in no event more than 14 days from the date of the medical treatment recommendation by the physician. In cases where the review is retrospective, the decision shall be communicated to the individual who received services, or to the individual's designee, within 30 days of receipt of information that is reasonably necessary to make this determination. (2) When the employee's condition is such that the employee faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other major bodily function, or the normal timeframe for the decision making process, as described in paragraph (1), would be detrimental to the employee's life or health or could jeopardize the employee's ability to regain maximum function, decisions to approve, modify, delay, or deny requests by physicians prior to, or concurrent with, the provision of medical treatment services to employees shall be made in a timely fashion that is appropriate for the nature of the employee's condition, but not to exceed 72 hours after the receipt of the information reasonably necessary to make the determination. (3) (A) Decisions to approve, modify, delay, or deny requests by physicians for authorization prior to, or concurrent with, the provision of medical treatment services to employees shall be communicated to the requesting physician within

87 24 hours of the decision. Decisions resulting in modification, delay, or denial of all or part of the requested health care service shall be communicated to physicians initially by telephone or facsimile, and to the physician and employee in writing within 24 hours for concurrent review, or within two business days of the decision for prospective review, as prescribed by the administrative director. If the request is not approved in full, disputes shall be resolved in accordance with Section If a request to perform spinal surgery is denied, disputes shall be resolved in accordance with subdivision (b) of Section (B) In the case of concurrent review, medical care shall not be discontinued until the employee's physician has been notified of the decision and a care plan has been agreed upon by the physician that is appropriate for the medical needs of the employee. Medical care provided during a concurrent review shall be care that is medically necessary to cure and relieve, and an insurer or self-insured employer shall only be liable for those services determined medically necessary to cure and relieve. If the insurer or self-insured employer disputes whether or not one or more services offered concurrently with a utilization review were medically necessary to cure and relieve, the dispute shall be resolved pursuant to Section 4062, except in cases involving recommendations for the performance of spinal surgery, which shall be governed by the provisions of subdivision (b) of Section Any compromise between the parties that an insurer or self-insured employer believes may result in payment for services that were not medically necessary to cure and relieve shall be reported by the insurer or the self-insured employer to the licensing board of the provider or providers who received the payments, in a manner set forth by the respective board and in such a way as to minimize reporting costs both to the board and to the insurer or self-insured employer, for evaluation as to possible violations of the statutes governing appropriate professional practices. No fees shall be levied upon insurers or selfinsured employers making reports required by this section. (4) Communications regarding decisions to approve requests by physicians shall specify the specific medical treatment service approved. Responses regarding decisions to modify, delay, or deny medical treatment services requested by physicians shall include a clear and concise explanation of the reasons for the employer's decision, a description of the criteria or guidelines used, and the clinical reasons for the decisions regarding medical necessity. (5) If the employer, insurer, or other entity cannot make a decision within the timeframes specified in paragraph (1) or (2) because the employer or other entity is not in receipt of all of the information reasonably necessary and requested, because the employer requires consultation by an expert reviewer, or because the employer has asked that an additional examination or test be performed upon the employee that is reasonable and consistent with good medical practice, the employer shall immediately notify the physician and the employee, in writing, that the employer cannot make a decision within the required timeframe, and specify the information requested but not received, the expert reviewer to be consulted, or the additional examinations or tests required. The employer shall also

88 notify the physician and employee of the anticipated date on which a decision may be rendered. Upon receipt of all information reasonably necessary and requested by the employer, the employer shall approve, modify, or deny the request for authorization within the timeframes specified in paragraph (1) or (2). (h) Every employer, insurer, or other entity subject to this section shall maintain telephone access for physicians to request authorization for health care services. (i) If the administrative director determines that the employer, insurer, or other entity subject to this section has failed to meet any of the timeframes in this section, or has failed to meet any other requirement of this section, the administrative director may assess, by order, administrative penalties for each failure. A proceeding for the issuance of an order assessing administrative penalties shall be subject to appropriate notice to, and an opportunity for a hearing with regard to, the person affected. The administrative penalties shall not be deemed to be an exclusive remedy for the administrative director. These penalties shall be deposited in the Workers' Compensation Administration Revolving Fund

89 Utilization Review Standards Definitions As used in this Article: (a) ACOEM Practice Guidelines means the American College of Occupational and Environmental Medicine s Occupational Medicine Practice Guidelines, Second Edition. (b) Authorization means assurance that appropriate reimbursement will be made for an approved specific course of proposed medical treatment to cure or relieve the effects of the industrial injury pursuant to section 4600 of the Labor Code, subject to the provisions of section 5402 of the Labor Code, based on the Doctor s First Report of Occupational Injury or Illness, Form DLSR 5021, or on the Primary Treating Physician s Progress Report, DWC Form PR-2, as contained in section , or in narrative form containing the same information required in the DWC Form PR-2. (c) "Claims Administrator" is a self-administered workers' compensation insurer, an insured employer, a self-administered self-insured employer, a self-administered legally uninsured employer, a self-administered joint powers authority, a third-party claims administrator or other entity subject to Labor Code section The claims administrator may utilize an entity contracted to conduct its utilization review responsibilities. (d) Concurrent review means utilization review conducted during an inpatient stay. (e) Course of treatment means the course of medical treatment set forth in the treatment plan contained on the Doctor s First Report of Occupational Injury or Illness, Form DLSR 5021, or on the Primary Treating Physician s Progress Report, DWC Form PR-2, as contained in section or in narrative form containing the same information required in the DWC Form PR-2. (f) Emergency health care services means health care services for a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to place the patient's health in serious jeopardy. (g) Expedited review means utilization review conducted when the injured worker s condition is such that the injured worker faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other major bodily function, or the normal timeframe for the decision-making process would be detrimental to the injured worker s life or health or could jeopardize the injured worker s permanent ability to regain maximum function. (h) Expert reviewer means a medical doctor, doctor of osteopathy, psychologist, acupuncturist, optometrist, dentist, podiatrist, or chiropractic practitioner licensed by any state or the District of Columbia, competent to evaluate the specific clinical issues involved in the medical treatment services and where these services are within the individual s scope of practice, who has been consulted by the reviewer or the utilization review medical director to provide specialized review of medical information

90 (i) "Health care provider" means a provider of medical services, as well as related services or goods, including but not limited to an individual provider or facility, a health care service plan, a health care organization, a member of a preferred provider organization or medical provider network as provided in Labor Code section (j) Immediately means within 24 hours after learning the circumstances that would require an extension of the timeframe for decisions specified in subdivisions (b)(1), (b)(2) or (c) and (g)(1) of section (k) Material modification is when the claims administrator changes utilization review vendor or makes a change to the utilization review standards as specified in section (l) Medical Director is the physician and surgeon licensed by the Medical Board of California or the Osteopathic Board of California who holds an unrestricted license to practice medicine in the State of California. The Medical Director is responsible for all decisions made in the utilization review process. (m) "Medical services" means those goods and services provided pursuant to Article 2 (commencing with Labor Code section 4600) of Chapter 2 of Part 2 of Division 4 of the Labor Code. (n) Prospective review means any utilization review conducted, except for utilization review conducted during an inpatient stay, prior to the delivery of the requested medical services. (o) "Request for authorization" means a written confirmation of an oral request for a specific course of proposed medical treatment pursuant to Labor Code section 4610(h) or a written request for a specific course of proposed medical treatment. An oral request for authorization must be followed by a written confirmation of the request within seventy-two (72) hours. Both the written confirmation of an oral request and the written request must be set forth on the Doctor s First Report of Occupational Injury or Illness, Form DLSR 5021, section 14006, or on the Primary Treating Physician Progress Report, DWC Form PR-2, as contained in section , or in narrative form containing the same information required in the PR-2 form. If a narrative format is used, the document shall be clearly marked at the top that it is a request for authorization. (p) Retrospective review means utilization review conducted after medical services have been provided and for which approval has not already been given. (q) Reviewer means a medical doctor, doctor of osteopathy, psychologist, acupuncturist, optometrist, dentist, podiatrist, or chiropractic practitioner licensed by any state or the District of Columbia, competent to evaluate the specific clinical issues involved in medical treatment services, where these services are within the scope of the reviewer s practice

91 (r) Utilization review plan means the written plan filed with the Administrative Director pursuant to Labor Code section 4610, setting forth the policies and procedures, and a description of the utilization review process. (s) "Utilization review process" means utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, delay, or deny, based in whole or in part on medical necessity to cure or relieve, treatment recommendations by physicians, as defined in Labor Code section , prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Labor Code section Utilization review does not include determinations of the work-relatedness of injury or disease, or bill review for the purpose of determining whether the medical services were accurately billed. (t) "Written" includes a facsimile as well as communications in paper form. Authority: Sections 133, , and , Labor Code. Reference: Sections , 4062, 4600, , , and 4610, Labor Code

92 Utilization Review Standards Applicability (a) Effective January 1, 2004, every claims administrator shall establish and maintain a utilization review process for treatment rendered on or after January 1, 2004, regardless of date of injury, in compliance with Labor Code section Each utilization review process shall be set forth in a utilization review plan which shall contain: (1) The name, address, phone number, and medical license number of the employed or designated medical director, who holds an unrestricted license to practice medicine in the state of California issued pursuant to section 2050 or section 2450 of the Business and Professions Code. (2) A description of the process whereby requests for authorization are reviewed, and decisions on such requests are made, and a description of the process for handling expedited reviews. (3) A description of the specific criteria utilized routinely in the review and throughout the decision-making process, including treatment protocols or standards used in the process. A description of the personnel and other sources used in the development and review of the criteria, and methods for updating the criteria. Prior to and until the Administrative Director adopts a medical treatment utilization schedule pursuant to Labor Code section , the written policies and procedures governing the utilization review process shall be consistent with the recommended standards set forth in the American College of Occupational and Environmental Medicine s Occupational Medicine Practice Guidelines, Second Edition. The Administrative Director incorporates by reference the American College of Occupational and Environmental Medicine s Occupational Medicine Practice Guidelines (ACOEM), Second Edition (2004), published by OEM Press. A copy may be obtained from OEM Press, 8 West Street, Beverly Farms, Massachusetts ( After the Administrative Director adopts a medical treatment utilization schedule pursuant to Labor Code section , the written policies and procedures governing the utilization review process shall be consistent with the recommended standards set forth in that schedule. (4) A description of the qualifications and functions of the personnel involved in decision-making and implementation of the utilization review plan. (5) A description of the claims administrator s practice, if applicable, of any prior authorization process, including but not limited to, where authorization is provided without the submission of the request for authorization. (b) (1) The medical director shall ensure that the process by which the claims administrator reviews and approves, modifies, delays, or denies requests by physicians prior to, retrospectively, or concurrent with the provision of medical services, complies with Labor Code section 4610 and these implementing regulations

93 (2) A reviewer who is competent to evaluate the specific clinical issues involved in the medical treatment services, and where these services are within the reviewer s scope of practice, may, except as indicated below, delay, modify or deny, requests for authorization of medical treatment for reasons of medical necessity to cure or relieve the effects of the industrial injury. (3) A non-physician reviewer may be used to initially apply specified criteria to requests for authorization for medical services. A non-physician reviewer may approve requests for authorization of medical services. A non-physician reviewer may discuss applicable criteria with the requesting physician, should the treatment for which authorization is sought appear to be inconsistent with the criteria. In such instances, the requesting physician may voluntarily withdraw a portion or all of the treatment in question and submit an amended request for treatment authorization, and the non-physician reviewer may approve the amended request for treatment authorization. Additionally, a nonphysician reviewer may reasonably request appropriate additional information that is necessary to render a decision but in no event shall this exceed the time limitations imposed in section subdivisions (b)(1), (b)(2) or (c). Any time beyond the time specified in these paragraphs is subject to the provisions of subdivision (g)(1)(a) through (g)(1)(c) of section (c) The complete utilization review plan, consisting of the policies and procedures, and a description of the utilization review process, shall be filed by the claims administrator, or by the external utilization review organization contracted by the claims administrator to perform the utilization review, with the Administrative Director. In lieu of filing the utilization review plan, the claims administrator may submit a letter identifying the external utilization review organization which has been contracted to perform the utilization review functions, provided that the utilization review organization has filed a complete utilization review plan with the Administrative Director. A modified utilization review plan shall be filed with the Administrative Director within 30 calendar days after the claims administrator makes a material modification to the plan. (d) Upon request by the public, the claims administrator shall make available the complete utilization review plan, consisting of the policies and procedures, and a description of the utilization review process. (1) The claims administrator may make available the complete utilization review plan, consisting of the policies and procedures and a description of the utilization review process, through electronic means. If a member of the public requests a hard copy of the utilization review plan, the claims administrator may charge reasonable copying and postage expenses related to disclosing the complete utilization review plan. Such charge shall not exceed $0.25 per page plus actual postage costs. Authority: Sections 133, , and , Labor Code. Reference: Sections 4062, 4600, , , and 4610, Labor Code

94 Utilization Review Standards Medically-Based Criteria (a) (1) The criteria shall be consistent with the schedule for medical treatment utilization adopted pursuant to Labor Code section Prior to adoption of the schedule, the criteria or guidelines used in the utilization review process shall be consistent with the American College of Occupational and Environmental Medicine s (ACOEM) Practice Guidelines, Second Edition. The guidelines set forth in the ACOEM Practice Guidelines shall be presumptively correct on the issue of extent and scope of medical treatment until the effective date of the utilization schedule adopted pursuant to Labor Code section The presumption is rebuttable and may be controverted by a preponderance of the scientific medical evidence establishing that a variance from the guidelines is reasonably required to cure or relieve the injured worker from the effects of his or her injury. (2) For all conditions or injuries not addressed by the ACOEM Practice Guidelines or by the official utilization schedule after adoption pursuant to Labor Code section , authorized treatment shall be in accordance with other evidence-based medical treatment guidelines that are generally recognized by the national medical community and are scientifically based. Treatment may not be denied on the sole basis that the treatment is not addressed by the ACOEM Practice Guidelines until adoption of the medical treatment utilization schedule pursuant to Labor Code section After the Administrative Director adopts a medical treatment utilization schedule pursuant to Labor Code section , treatment may not be denied on the sole basis that the treatment is not addressed by that schedule. (3) The relevant portion of the criteria or guidelines used shall be disclosed in written form to the requesting physician, the injured worker, and if the injured worker is represented by counsel, the injured worker s attorney, if used as the basis of a decision to modify, delay, or deny services in a specific case under review. The claims administrator may not charge an injured worker, the injured worker s attorney or the requesting physician for a copy of the relevant portion of the criteria or guidelines used to modify, delay or deny the treatment request. (4) Nothing in this section precludes authorization of medical treatment not included in the specific criteria under section (a)(3). Authority: Sections 133, , and , Labor Code. Reference: Sections 4062, 4600, , , and 4610, Labor Code

95 Utilization Review Standards Timeframe, Procedures and Notice Content (a) The request for authorization for a course of treatment as defined in section (e) must be in written form. (1) For purposes of this section, the written request for authorization shall be deemed to have been received by the claims administrator by facsimile on the date the request was received if the receiving facsimile electronically date stamps the transmission. If there is no electronically stamped date recorded, then the date the request was transmitted. A request for authorization transmitted by facsimile after 5:30 PM Pacific Time shall be deemed to have been received by the claims administrator on the following business day as defined in Labor Code section and in section 9 of the Civil Code. The copy of the request for authorization received by a facsimile transmission shall bear a notation of the date, time and place of transmission and the facsimile telephone number to which the request was transmitted or be accompanied by an unsigned copy of the affidavit or certificate of transmission which shall contain the facsimile telephone number to which the request was transmitted. The requesting physician must indicate the need for an expedited review upon submission of the request. (2) Where the request for authorization is made by mail, and a proof of service by mail exists, the request shall be deemed to have been received by the claims administrator five (5) days after the deposit in the mail at a facility regularly maintained by the United States Postal Service. Where the request for authorization is delivered via certified mail, return receipt mail, the request shall be deemed to have been received by the claims administrator on the receipt date entered on the return receipt. In the absence of a proof of service by mail or a dated return receipt, the request shall be deemed to have been received by the claims administrator on the date stamped as received on the document. (b) The utilization review process shall meet the following timeframe requirements: (1) Prospective or concurrent decisions shall be made in a timely fashion that is appropriate for the nature of the injured worker s condition, not to exceed five (5) working days from the date of receipt of the written request for authorization. (2) If appropriate information which is necessary to render a decision is not provided with the original request for authorization, such information may be requested by a reviewer or non-physician reviewer within five (5) working days from the date of receipt of the written request for authorization to make the proper determination. In no event shall the determination be made more than 14 days from the date of receipt of the original request for authorization by the health care provider. (A) If the reasonable information requested by the claims administrator is not received within 14 days of the date of the original written request by the requesting physician, a reviewer may deny the request with the stated condition that the request will be reconsidered upon receipt of the information requested

96 (3) Decisions to approve a physician s request for authorization prior to, or concurrent with, the provision of medical services to the injured worker shall be communicated to the requesting physician within 24 hours of the decision. Any decision to approve a request shall be communicated to the requesting physician initially by telephone or facsimile. The communication by telephone shall be followed by written notice to the requesting physician within 24 hours of the decision for concurrent review and within two business days for prospective review. (4) Decisions to modify, delay or deny a physician s request for authorization prior to, or concurrent with the provision of medical services to the injured worker shall be communicated to the requesting physician initially by telephone or facsimile. The communication by telephone shall be followed by written notice to the requesting physician, the injured worker, and if the injured worker is represented by counsel, the injured worker s attorney within 24 hours of the decision for concurrent review and within two business days of the decision for prospective review. In addition, the nonphysician provider of goods or services identified in the request for authorization, and for whom contact information has been included, shall be notified in writing of the decision modifying, delaying, or denying a request for authorization that shall not include the rationale, criteria or guidelines used for the decision. (5) For purposes of this section normal business day means a business day as defined in Labor Code section and Civil Code section 9. (c) When review is retrospective, decisions shall be communicated to the requesting physician who provided the medical services and to the individual who received the medical services, and his or her attorney/designee, if applicable, within 30 days of receipt of the medical information that is reasonably necessary to make this determination. In addition, the non-physician provider of goods or services identified in the request for authorization, and for whom contact information has been included, shall be notified in writing of the decision modifying, delaying, or denying a request for authorization that shall not include the rationale, criteria or guidelines used for the decision. (d) Failure to obtain prior authorization for emergency health care services shall not be an acceptable basis for refusal to cover medical services provided to treat and stabilize an injured worker presenting for emergency health care services. Emergency health care services, however, may be subjected to retrospective review. Documentation for emergency health care services shall be made available to the claims administrator upon request. (e) Prospective or concurrent decisions related to an expedited review shall be made in a timely fashion appropriate to the injured worker s condition, not to exceed 72 hours after the receipt of the written information reasonably necessary to make the determination. The requesting physician must indicate the need for an expedited review upon submission of the request. Decisions related to expedited review refer to the following situations:

97 (1) When the injured worker s condition is such that the injured worker faces an imminent and serious threat to his or her health, including, but not limited to, the potential loss of life, limb, or other major bodily function, or (2) The normal timeframe for the decision-making process, as described in subdivision (b), would be detrimental to the injured worker s life or health or could jeopardize the injured worker s permanent ability to regain maximum function. (f) The review and decision to deny, delay or modify a request for medical treatment must be conducted by a reviewer, who is competent to evaluate the specific clinical issues involved in the medical treatment services, and where these services are within the scope of the individual s practice. (g) (1) The timeframe for decisions specified in subdivisions (b)(1), (b)(2) or (c) may only be extended by the claims administrator under the following circumstances: (A) The claims administrator is not in receipt of all of the necessary medical information reasonably requested. (B) The reviewer has asked that an additional examination or test be performed upon the injured worker that is reasonable and consistent with professionally recognized standards of medical practice. (C) The claims administrator needs a specialized consultation and review of medical information by an expert reviewer. (2) If subdivisions (A), (B) or (C) above apply, the claims administrator shall immediately notify the requesting physician, the injured worker, and if the injured worker is represented by counsel, the injured worker s attorney in writing, that the claims administrator cannot make a decision within the required timeframe, and specify the information requested but not received, the additional examinations or tests required, or the specialty of the expert reviewer to be consulted. The claims administrator shall also notify the requesting physician, the injured worker, and if the injured worker is represented by counsel, the injured worker s attorney of the anticipated date on which a decision will be rendered. This notice shall include a statement that if the injured worker believes that a bona fide dispute exists relating to his or her entitlement to medical treatment, the injured worker or the injured worker s attorney may file an Application for Adjudication of Claim and Request for Expedited Hearing, DWC Form 4, in accordance with sections 10136(b)(1), 10400, and In addition, the non-physician provider of goods or services identified in the request for authorization, and for whom contact information has been included, shall be notified in writing of the decision to extend the timeframe and the anticipated date on which the decision will be rendered in accordance with this subdivision. The written notification shall not include the rationale, criteria or guidelines used for the decision

98 (3) Upon receipt of information pursuant to subdivisions (A), (B), or (C) above, and (b)(2)(a), the claims administrator shall make the decision to approve and the reviewer shall make a decision to modify or deny the request for authorization within five (5) working days of receipt of the information for prospective or concurrent review. The decision shall be communicated pursuant to subdivisions (b)(3) or (b)(4). (4) Upon receipt of information pursuant to subdivisions (A), (B), or (C) above, the claims administrator shall make the decision to approve and the reviewer shall make a decision to modify or deny the request for authorization within thirty (30) days of receipt of the information for retrospective review. (h) Every claims administrator shall maintain telephone access from 9:00 AM to 5:30 PM Pacific Time, on normal business days, for health care providers to request authorization for medical services. Every claims administrator shall have a facsimile number available for physicians to request authorization for medical services. Every claims administrator shall maintain a process to receive communications from health care providers requesting authorization for medical services after business hours. For purposes of this section normal business day means a business day as defined in Labor Code section and Civil Code section 9. In addition, for purposes of this section the requirement that the claims administrator maintain a process to receive communications from requesting physicians after business hours shall be satisfied by maintaining a voice mail system or a facsimile number for after business hours requests. (i) A written decision approving a request for treatment authorization under this section shall specify the specific medical treatment service approved. (j) A written decision modifying, delaying or denying treatment authorization under this section shall be provided to the requesting physician, the injured worker, and if the injured worker is represented by counsel, the injured worker s attorney and shall contain the following information: (1) The date on which the decision is made. (2) A description of the specific course of proposed medical treatment for which authorization was requested. (3) A specific description of the medical treatment service approved, if any. (4) A clear and concise explanation of the reasons for the claims administrator s decision. (5) A description of the medical criteria or guidelines used pursuant to section , subdivision (a)(3). (6) The clinical reasons regarding medical necessity. (7) A clear statement that any dispute shall be resolved in accordance with the provisions of Labor Code section 4062, and that an objection to the utilization review decision must

99 be communicated by the injured worker or the injured worker s attorney on behalf of the injured worker to the claims administrator in writing within 20 days of receipt of the decision. It shall further state that the 20-day time limit may be extended for good cause or by mutual agreement of the parties. The letter shall further state that the injured worker may file an Application for Adjudication of Claim and Request for Expedited Hearing, DWC Form 4, showing a bona fide dispute as to entitlement to medical treatment in accordance with sections 10136(b)(1), 10400, and (8) Include the following mandatory language: Either "If you want further information, you may contact the local state Information and Assistance office by calling [enter district I & A office telephone number closest to the injured worker] or you may receive recorded information by calling or If you want further information, you may contact the local state Information and Assistance office closest to you. Please see attached listing (attach a listing of I&A offices and telephone numbers) or you may receive recorded information by calling and You may also consult an attorney of your choice. Should you decide to be represented by an attorney, you may or may not receive a larger award, but, unless you are determined to be ineligible for an award, the attorney's fee will be deducted from any award you might receive for disability benefits. The decision to be represented by an attorney is yours to make, but it is voluntary and may not be necessary for you to receive your benefits." In addition, the non-physician provider of goods or services identified in the request for authorization, and for whom contact information has been included, shall be notified in writing of the decision modifying, delaying, or denying a request for authorization that shall not include the rationale, criteria or guidelines used for the decision. (9) Details about the claims administrator s internal utilization review appeals process, if any, and a clear statement that the appeals process is on a voluntary basis, including the following mandatory statement: "If you disagree with the utilization review decision and wish to dispute it, you must send written notice of your objection to the claims administrator within 20 days of receipt of the utilization review decision in accordance with Labor Code section You must

100 meet this deadline even if you are participating in the claims administrator s internal utilization review appeals process. (k) The written decision modifying, delaying or denying treatment authorization provided to the requesting physician shall also contain the name and specialty of the reviewer or expert reviewer, and the telephone number in the United States of the reviewer or expert reviewer. The written decision shall also disclose the hours of availability of either the reviewer, the expert reviewer or the medical director for the treating physician to discuss the decision which shall be, at a minimum, four (4) hours per week during normal business hours, 9:00 AM to 5:30 PM., Pacific Time or an agreed upon scheduled time to discuss the decision with the requesting physician. In the event the reviewer is unavailable, the requesting physician may discuss the written decision with another reviewer who is competent to evaluate the specific clinical issues involved in the medical treatment services. (l) Authorization may not be denied on the basis of lack of information without documentation reflecting an attempt to obtain the necessary information from the physician or from the provider of goods or services identified in the request for authorization either by facsimile or mail. Authority: Sections 133, , and , Labor Code. Reference: Sections 4062, 4600, , , and 4610, Labor Code

101 Utilization Review Standards Dispute Resolution (a) (1) If the request for authorization of medical treatment is not approved, or if the request for authorization for medical treatment is approved in part, any dispute shall be resolved in accordance with Labor Code section (2) An objection to a decision disapproving in whole or in part a request for authorization of medical treatment, must be communicated to the claims administrator by the injured worker or the injured worker s attorney in writing within 20 days of receipt of the utilization review decision. The 20-day time limit may be extended for good cause or by mutual agreement of the parties. (3) Nothing in this paragraph precludes the parties from participating in an internal utilization review appeal process on a voluntary basis provided the injured worker and if the injured worker is represented by counsel, the injured worker s attorney have been notified of the 20-day time limit to file an objection to the utilization review decision in accordance with Labor Code section (4) Additionally, the injured worker or the injured worker s attorney may file an Application for Adjudication of Claim, and a Request for Expedited Hearing, DWC Form 4, in accordance with sections 10136(b)(1), 10400, and 10408, and request an expedited hearing and decision on his or her entitlement to medical treatment if the request for medical treatment is not authorized within the time limitations set forth in section , or when there exists a bona fide dispute as to entitlement to medical treatment. (b) The following requirements shall be met prior to a concurrent review decision to deny authorization for medical treatment and to resolve disputes: (1) In the case of concurrent review, medical care shall not be discontinued until the requesting physician has been notified of the decision and a care plan has been agreed upon by the requesting physician that is appropriate for the medical needs of the injured worker. In addition, the non-physician provider of goods or services identified in the request for authorization, and for whom contact information has been included, shall be notified in writing of the decision modifying, delaying, or denying a request for authorization that shall not include the rationale, criteria or guidelines used for the decision. (2) Medical care provided during a concurrent review shall be medical treatment that is reasonably required to cure or relieve from the effects of the industrial injury. Authority: Sections 133, , and , Labor Code. Reference: Sections 4062, 4600, , , and 4610, Labor Code

102 9785. Reporting Duties of the Primary Treating Physician. (a) For the purposes of this section, the following definitions apply: (1) The primary treating physician is the physician who is primarily responsible for managing the care of an employee, and who has examined the employee at least once for the purpose of rendering or prescribing treatment and has monitored the effect of the treatment thereafter. The primary treating physician is the physician selected by the employer, the employee pursuant to Article 2 (commencing with section 4600) of Chapter 2 of Part 2 of Division 4 of the Labor Code, or under the contract or procedures applicable to a Health Care Organization certified under section of the Labor Code, or in accordance with the physician selection procedures contained in the medical provider network pursuant to Labor Code section (2) A secondary physician is any physician other than the primary treating physician who examines or provides treatment to the employee, but is not primarily responsible for continuing management of the care of the employee. (3) Claims administrator is a self-administered insurer providing security for the payment of compensation required by Divisions 4 and 4.5 of the Labor Code, a selfadministered self-insured employer, or a third-party administrator for a self-insured employer, insurer, legally uninsured employer, or joint powers authority. (4) Medical determination means, for the purpose of this section, a decision made by the primary treating physician regarding any and all medical issues necessary to determine the employee's eligibility for compensation. Such issues include but are not limited to the scope and extent of an employee's continuing medical treatment, the decision whether to release the employee from care, the point in time at which the employee has reached permanent and stationary status, and the necessity for future medical treatment. (5) Released from care means a determination by the primary treating physician that the employee's condition has reached a permanent and stationary status with no need for continuing or future medical treatment. (6) Continuing medical treatment is occurring or presently planned treatment that is reasonably required to cure or relieve the employee from the effects of the injury. (7) Future medical treatment is treatment which is anticipated at some time in the future and is reasonably required to cure or relieve the employee from the effects of the injury. (8) Permanent and stationary status is the point when the employee has reached maximal medical improvement, meaning his or her condition is well stabilized, and unlikely to change substantially in the next year with or without medical treatment. (b) (1) An employee shall have no more than one primary treating physician at a time

103 (2) An employee may designate a new primary treating physician of his or her choice pursuant to Labor Code 4600 or provided the primary treating physician has determined that there is a need for: (A) continuing medical treatment; or (B) future medical treatment. The employee may designate a new primary treating physician to render future medical treatment either prior to or at the time such treatment becomes necessary. (3) If the employee disputes a medical determination made by the primary treating physician, including a determination that the employee should be released from care, or if the employee objects to a decision made pursuant to Labor Code section 4610 to modify, delay, or deny a treatment recommendation, the dispute shall be resolved under the applicable procedures set forth at Labor Code sections4061 and No other primary treating physician shall be designated by the employee unless and until the dispute is resolved. (4) If the claims administrator disputes a medical determination made by the primary treating physician, the dispute shall be resolved under the applicable procedures set forth at Labor Code sections 4610, 4061 and (c) The primary treating physician, or a physician designated by the primary treating physician, shall make reports to the claims administrator as required in this section. A primary treating physician has fulfilled his or her reporting duties under this section by sending one copy of a required report to the claims administrator. A claims administrator may designate any person or entity to be the recipient of its copy of the required report. (d) The primary treating physician shall render opinions on all medical issues necessary to determine the employee's eligibility for compensation in the manner prescribed in subdivisions (e), (f) and (g) of this section. The primary treating physician may transmit reports to the claims administrator by mail or FAX or by any other means satisfactory to the claims administrator, including electronic transmission. (e) (1) Within 5 working days following initial examination, a primary treating physician shall submit a written report to the claims administrator on the form entitled Doctor's First Report of Occupational Injury or Illness, Form DLSR Emergency and urgent care physicians shall also submit a Form DLSR 5021 to the claims administrator following the initial visit to the treatment facility. On line 24 of the Doctor's First Report, or on the reverse side of the form, the physician shall (A) list methods, frequency, and duration of planned treatment(s), (B) specify planned consultations or referrals, surgery or hospitalization and (C) specify the type, frequency and duration of planned physical medicine services (e.g., physical therapy, manipulation, acupuncture)

104 (2) Each new primary treating physician shall submit a Form DLSR 5021 following the initial examination in accordance with subdivision (e)(1). (3) Secondary physicians, physical therapists, and other health care providers to whom the employee is referred shall report to the primary treating physician in the manner required by the primary treating physician. (4) The primary treating physician shall be responsible for obtaining all of the reports of secondary physicians and shall, unless good cause is shown, within 20 days of receipt of each report incorporate, or comment upon, the findings and opinions of the other physicians in the primary treating physician's report and submit all of the reports to the claims administrator. (f) A primary treating physician shall, unless good cause is shown, within 20 days report to the claims administrator when any one or more of the following occurs: (1) The employee's condition undergoes a previously unexpected significant change; (2) There is any significant change in the treatment plan reported, including, but not limited to, (A) an extension of duration or frequency of treatment, (B) a new need for hospitalization or surgery, (C) a new need for referral to or consultation by another physician, (D) a change in methods of treatment or in required physical medicine services, or (E) a need for rental or purchase of durable medical equipment or orthotic devices; (3) The employee's condition permits return to modified or regular work; (4) The employee's condition requires him or her to leave work, or requires changes in work restrictions or modifications; (5) The employee is released from care; (6) The primary treating physician concludes that the employee's permanent disability precludes, or is likely to preclude, the employee from engaging in the employee's usual occupation or the occupation in which the employee was engaged at the time of the injury, as required pursuant to Labor Code Section 4636(b); (7) The claims administrator reasonably requests appropriate additional information that is necessary to administer the claim. Necessary information is that which directly affects the provision of compensation benefits as defined in Labor Code Section (8) When continuing medical treatment is provided, a progress report shall be made no later than forty-five days from the last report of any type under this section even if no event described in paragraphs (1) to (7) has occurred. If an examination has occurred, the report shall be signed and transmitted within 20 days of the examination

105 Except for a response to a request for information made pursuant to subdivision (f)(7), reports required under this subdivision shall be submitted on the Primary Treating Physician's Progress Report form (Form PR-2) contained in Section , or in the form of a narrative report. If a narrative report is used, it must be entitled Primary Treating Physician's Progress Report in bold-faced type, must indicate clearly the reason the report is being submitted, and must contain the same information using the same subject headings in the same order as Form PR-2. A response to a request for information made pursuant to subdivision (f)(7) may be made in letter format. A narrative report and a letter format response to a request for information must contain the same declaration under penalty of perjury that is set forth in the Form PR-2: I declare under penalty of perjury that this report is true and correct to the best of my knowledge and that I have not violated Labor Code By mutual agreement between the physician and the claims administrator, the physician may make reports in any manner and form. (g) When the primary treating physician determines that the employee's condition is permanent and stationary, the physician shall, unless good cause is shown, report within 20 days from the date of examination any findings concerning the existence and extent of permanent impairment and limitations and any need for continuing and/or future medical care resulting from the injury. The information may be submitted on the Primary Treating Physician's Permanent and Stationary Report form (DWC Form PR-3 or DWC Form PR-4) contained in section or section , or in such other manner which provides all the information required by Title 8, California Code of Regulations, section For permanent disability evaluation performed pursuant to the permanent disability evaluation schedule adopted on or after January 1, 2005, the primary treating physician's reports concerning the existence and extent of permanent impairment shall describe the impairment in accordance with the AMA Guides to the Evaluation on Permanent Impairment, 5th Edition (DWC Form PR-4). Qualified Medical Evaluators and Agreed Medical Evaluators may not use DWC Form PR-3 or DWC Form PR-4 to report medical-legal evaluations. (h) Any controversies concerning this section shall be resolved pursuant to Labor Code Section 4603 or 4604, whichever is appropriate. (i) Claims administrators shall reimburse primary treating physicians for their reports submitted pursuant to this section as required by the Official Medical Fee Schedule. NOTE Authority cited: Sections 133, and , Labor Code. Reference: Sections 4061, , 4062, 4600, , , 4636, 4660, 4662, 4663 and 4664, Labor Code. HISTORY 1. Amendment filed ; effective thirtieth day thereafter (Register 77, No. 46). 2. Amendment of subsection (b) filed ; effective thirtieth day thereafter (Register 78, No. 45)

106 3. Amendment of subsections (c) and (d) and new subsection (e) filed ; operative (Register 89, No. 28). 4. Amendment of section and Note filed ; operative Submitted to OAL for printing only pursuant to Government Code section (Register 93, No. 36). 5. New subsection (e) and subsection relettering filed ; operative Submitted to OAL for printing only pursuant to Government Code section (Register 95, No. 13). 6. Repealer and new section filed ; operative (Register 98, No. 46). 7. Amendment of subsections (e)(1), (f)(8) and (g) filed ; operative pursuant to Government Code section (d) (Register 2000, No. 51). 8. Amendment of section and Note filed ; operative (Register 2003, No. 21). 9. Amendment of subsections (a)(1), (a)(8), (b)(3)-(4) and (g) and amendment of Note filed as an emergency; operative (Register 2004, No. 53). A Certificate of Compliance must be transmitted to OAL by or emergency language will be repealed by operation of law on the following day. 10. Certificate of Compliance as to order, including further amendment of subsections (a)(1) and (g), transmitted to OAL and filed (Register 2005, No. 23)

107 Illinois Workers' Compensation Act 820 ILCS 305 Addenda Illinois Requirements Section 8.7. Utilization review programs. (a) As used in this Section: "Utilization review" means the evaluation of proposed or provided health care services to determine the appropriateness of both the level of health care services medically necessary and the quality of health care services provided to a patient, including evaluation of their efficiency, efficacy, and appropriateness of treatment, hospitalization, or office visits based on medically accepted standards. The evaluation must be accomplished by means of a system that identifies the utilization of health care services based on standards of care or nationally recognized peer review guidelines as well as nationally recognized evidence based upon standards as provided in this Act. Utilization techniques may include prospective review, second opinions, concurrent review, discharge planning, peer review, independent medical examinations, and retrospective review (for purposes of this sentence, retrospective review shall be applicable to services rendered on or after July 20, 2005). Nothing in this Section applies to prospective review of necessary first aid or emergency treatment. (b) No person may conduct a utilization review program for workers' compensation services in this State unless once every 2 years the person registers the utilization review program with the Department of Financial and Professional Regulation and certifies compliance with the Workers' Compensation Utilization Management standards or Health Utilization Management Standards of URAC sufficient to achieve URAC accreditation or submits evidence of accreditation by URAC for its Workers' Compensation Utilization Management Standards or Health Utilization Management Standards. Nothing in this Act shall be construed to require an employer or insurer or its subcontractors to become URAC accredited. (c) In addition, the Secretary of Financial and Professional Regulation may certify alternative utilization review standards of national accreditation organizations or entities in order for plans to comply with this Section. Any alternative utilization review standards shall meet or exceed those standards required under subsection (b). (d) This registration shall include submission of all of the following information regarding utilization review program activities: (1) The name, address, and telephone number of the utilization review programs. (2) The organization and governing structure of the utilization review programs. (3) The number of lives for which utilization review is conducted by each utilization review program. (4) Hours of operation of each utilization review program. (5) Description of the grievance process for each utilization review program. (6) Number of covered lives for which utilization review was conducted for the previous calendar year for each utilization review program. (7) Written policies and procedures for protecting confidential information according to

108 applicable State and federal laws for each utilization review program. (e) A utilization review program shall have written procedures to ensure that patient-specific information obtained during the process of utilization review will be: (1) kept confidential in accordance with applicable State and federal laws; and (2) shared only with the employee, the employee's designee, and the employee's health care provider, and those who are authorized by law to receive the information. Summary data shall not be considered confidential if it does not provide information to allow identification of individual patients or health care providers. Only a health care professional may make determinations regarding the medical necessity of health care services during the course of utilization review. When making retrospective reviews, utilization review programs shall base reviews solely on the medical information available to the attending physician or ordering provider at the time the health care services were provided. (f) If the Department of Financial and Professional Regulation finds that a utilization review program is not in compliance with this Section, the Department shall issue a corrective action plan and allow a reasonable amount of time for compliance with the plan. If the utilization review program does not come into compliance, the Department may issue a cease and desist order. Before issuing a cease and desist order under this Section, the Department shall provide the utilization review program with a written notice of the reasons for the order and allow a reasonable amount of time to supply additional information demonstrating compliance with the requirements of this Section and to request a hearing. The hearing notice shall be sent by certified mail, return receipt requested, and the hearing shall be conducted in accordance with the Illinois Administrative Procedure Act. (g) A utilization review program subject to a corrective action may continue to conduct business until a final decision has been issued by the Department. (h) The Secretary of Financial and Professional Regulation may by rule establish a registration fee for each person conducting a utilization review program. (i) A utilization review will be considered by the Commission, along with all other evidence and in the same manner as all other evidence, in the determination of the reasonableness and necessity of the medical bills or treatment. Nothing in this Section shall be construed to diminish the rights of employees to reasonable and necessary medical treatment or employee choice of health care provider under Section 8(a) or the rights of employers to medical examinations under Section 12. (j) When an employer denies payment of or refuses to authorize payment of first aid, medical, surgical, or hospital services under Section 8(a) of this Act, if that denial or refusal to authorize complies with a utilization review program registered under this Section and complies with all other requirements of this Section, then there shall be a rebuttable presumption that the employer shall not be responsible for payment of additional compensation pursuant to Section 19(k) of this Act and if that denial or refusal to authorize does not comply with a utilization review program registered under this Section and does not comply with all other requirements of this Section, then that will be considered by the Commission, along with all other evidence and in the same manner as all other evidence, in the determination of whether the employer may be responsible for the payment of additional compensation pursuant to Section 19(k) of this Act

109 Addenda 6.01 Scope and Authority Massachusetts Requirements 452 CMR 6.00 is promulgated pursuant to M.G.L. c. 152, 5, 13, and CMR 6.00 shall apply to all claims for health care services: (a) requires workers' compensation insurers to undertake utilization review for all medical services to be provided to the injured employee after 12 weeks from the date of injury. The insurer may choose to undertake utilization review at any time during the 12 week period immediately following the date of injury. However, the insurer is mandated to undertake utilization review before denying any request for medical services during this initial 12 week period. Treatment guidelines are in effect during this 12 week period. (b) references the guidelines and review criteria that the Department of Industrial Accidents (DIA) requires providers to consider when treating certain medical conditions, and sets forth the mechanism for the development, endorsement, dissemination, and implementation of future guidelines; (c) sets forth the nature of utilization data that must be reported to the DIA; (d) sets forth the methods for quality assessment that will be used by the DIA; (e) sets forth the nature of the mechanisms that DIA will use to ensure compliance with 452 CMR 6.00; and (f) concerns the appropriateness of the health care service, i.e., whether the service is reasonable, necessary, and effective; and the quality of care provided to workers' compensation recipients, including consideration of the proper costs of services

110 6.02 Definitions Adverse Determination means a determination by the utilization review agent that a health care service has been reviewed, and based on the information provided, does not meet the clinical requirements for medical necessity and reasonableness of said service in accordance with medical guidelines. Approved Utilization Review Agent means any person or entity, insurer or self insurer, including the Commonwealth of Massachusetts, which has been authorized by the DIA to perform utilization review. Authorization means a determination by the utilization review agent that a health care service has been reviewed, and based on the information provided, meets the clinical requirements for medical necessity and reasonableness of said service in accordance with medical guidelines. Case Record means the complete record that is maintained by the utilization review agent and pertains to the injured employee's industrial injury. The case record shall include all of the following information and documents: date of injury; date of utilization review request; name of claim adjuster; name, address, telephone number, and school of ordering practitioner; International Classification of Disease (ICD) code and diagnosis; name, title, and credentials of utilization review staff; health care service requested; treatment guideline used to determine medical necessity; type and category of review; and supporting medical documentation. Cease and Desist Order means a written notice of a violation issued by the Commissioner pursuant to 452 CMR 6.00 et seq., when the Commissioner determines that a utilization review agent, insurer, or self insurer has failed to comply with all applicable laws, rules, regulations, orders, and requirements of the Commonwealth. Clinical Reviewer means a licensed health care professional who holds a non restricted license in any state. Commissioner means the Commissioner of the Department of Industrial Accidents (DIA). Concurrent Review means utilization review conducted during the patient s course of treatment. Department/DIA means Department of Industrial Accidents. Detailed Description of Services Rendered means pursuant to M.G.L. c. 152, 13 a report demonstrating the diagnosis, medical appropriateness of the service, pertinent physical findings, diagnostic and therapeutic procedures, prognosis, concurrent problems, and follow up care; the injured employee's functional limitations, the ability to perform either regular duties, limited duties, full or part time hours and whether the medical condition is at a point of maximum medical improvement. Emergency Treatment means care of an employee for a work related medical condition requiring immediate attention

111 Guidelines mean optimal strategies for patient management around which practice patterns should converge. Health Care Services means treatment services rendered to an injured employee by a provider pursuant to M.G.L. c Health Care Services Board means the Board created by M.G.L. c. 152, 13(3). Injury means personal injury as defined in M.G.L. c. 152, 1(7A). Insurer means an entity defined in M.G.L. c. 152, 1(7) and any self insured group as defined in M.G.L. c. 152, 25(E) through (U). Medical Condition means the physical or mental health status of an injured employee as determined by the provider administering health care services. Medical Director means a board certified physician duly licensed to practice in at least one state in the United States, and in active practice at least eight hours per week. The OHP may waive the active practice requirement for otherwise qualified, licensed physicians with administrative experience in utilization review oversight or quality assessment. Each utilization review organization shall have available a licensed medical director to provide for clinical oversight of the utilization review program. Medical Report means a report of the Initial Industrial Accident office visit as defined in CMR pursuant to 452 CMR 1.13(1). OHP means Office of Health Policy which is a division of the DIA. Patient Satisfaction Measurement means use of a standard patient questionnaire form, including, but not limited to, the American College of Physicians questionnaire to determine a particular individual's satisfaction with his or her care. Practitioner means any person who is licensed to practice under the laws of the jurisdiction within which such health care services are rendered including physicians, dentists, chiropodists, chiropractors, optometrists, osteopaths, physical therapists, podiatrists, psychologists, and other licensed medical personnel. Preferred Provider Arrangement (PPA) means a contract between or on behalf of an organization and health care provider(s), as defined by M.G.L. c. 176I, 211 CMR and M.G.L. c. 152, to provide all or a specified portion of health care services resulting from workers' compensation claims against such organizations by covered persons. Probationary Approval means a temporary six month approval status after the utilization review agent fails a quality assessment audit. During this six month period, the utilization review agent may continue to conduct utilization review pending the results of interim follow up audits

112 Prospective Review means utilization review conducted prior to the delivery of the requested medical service. Provider means a practitioner, facility, or other organization providing health care services. Quality Assessment Tool is a guide used to evaluate the utilization review agent's quality assessment compliance rate. Retrospective Review means utilization review conducted after services have been rendered. School means a grouping of practitioners as defined by their professional degree. Schools include, but are not limited to, medical, physical and occupational therapy, chiropractic, osteopathic, allopathic, nursing and dentistry. Utilization Review concerns the quality of care provided to injured employees, including whether the service is appropriate and effective, the proper costs of services, and the quality of treatment. Appropriate service is health care service that is medically necessary and reasonable, and based on objective, clinical findings

113 6.03 Preferred Provider Arrangements under Workers Compensation (1) If an insurer receives approval of a preferred provider arrangement (PPA), an injured employee shall, if the arrangement is consented to by the employer and includes a provider in the specialty sought by the employee, be required to see a member of the preferred provider arrangement on the initial scheduled visit. Employees subject to any arrangement shall be provided information regarding their rights and obligations under M.G.L. c. 152, 30 and M.G.L. c. 176I upon initial approval of the preferred provider arrangement and annually thereafter. Such information shall also be posted in a prominent place in all worksites. (2) The list of names of the providers in the preferred provider arrangement within an employee's geographic region or of all health care providers within the arrangement organized geographically shall be distributed to each covered employee immediately following an alleged workplace injury. The names on such lists shall be arranged in order of medical specialty or provider type. A current list shall also be posted at a convenient and prominent place for covered persons to examine at worksites, and shall be given to any covered person upon request. (3) Any insurer approved as a preferred provider arrangement for workers' compensation must send to the Department of Industrial Accidents a duplicate copy of all information filed with the Division of Insurance together with a copy of its approval letter. (4) The Department of Industrial Accidents may require the approved PPA applicant to survey affected employees with a form of the Department's design to assess the employee's understanding of their rights with regard to participation in PPA's

114 6.04 Utilization Review by Insurers (1) Insurers and self insurers are required to undertake utilization review for health services rendered to injured employees, either by performing utilization review themselves or by contracting with a Commonwealth approved agent who will conduct utilization review services on their behalf. If an insurer or self insurer chooses to perform utilization review on its own, it must have its program approved through the OHP. Said utilization review program must remain separate and distinct from case management and all other claim functions. Utilization review organizations conducting Massachusetts reviews at multiple sites must seek separate approval for each site. For the conditions to which the treatment guidelines endorsed by the Health Care Services Board and adopted by the Commissioner pursuant to M.G.L. c. 152, 13 and 30 apply, the programs shall integrate said treatment guidelines. (2) Application for Approval. An applicant requesting approval to conduct utilization review in the Commonwealth shall: (a) submit a completed application to the OHP for each site where Massachusetts utilization review will be conducted, along with an initial application fee payable to the DIA. The application fee shall be $1, if the company is located in Massachusetts, excluding the Commonwealth and the various counties, cities, towns and districts; and $3, if the company is located outside of Massachusetts; (b) submit a new application to the OHP every two years, along with a renewal fee. The renewal fee shall be $ if the company is located in Massachusetts; and $1, if the company is located outside of Massachusetts; and (c) make arrangements with the OHP for a site visit for all new applicants. (3) Information Required with Application. To conduct utilization review in the Commonwealth, a utilization review agent must seek approval of its utilization review program from the Commissioner in writing and the application shall include, but not be limited to the following: (a) corporate and site demographics: name, address, and telephone number of the program's corporate, public, and Massachusetts contacts; and the identification of each site where Massachusetts utilization review will be conducted along with the name and number of the contact person for each site; (b) a list of all treatment guidelines which will be used by the licensed medical reviewer in rendering a determination, including DIA's Health Care Services Board Treatment Guidelines, secondary sources, and internally derived treatment guidelines. The utilization review agent shall also provide information pertaining to the procedures for implementing internal guidelines including the frequency of revisions;

115 (c) copies of all current professional licenses issued by the appropriate state licensing agency for all practitioners rendering utilization review determinations, including the medical director; (d) a detailed description of the appeal procedures for utilization review determinations, including copies of all materials designed to inform injured employees of the requirements of the utilization review program and their responsibilities and rights under the program; (e) the identity of each insurer/self insurer for which the utilization review agent performs Massachusetts reviews; (f) an attestation in writing that the utilization review agent shall comply with all applicable laws, rules, regulations, orders, and requirements of the Commonwealth; and (g) disclosure of any economic incentives for reviewers in the utilization review program. Any material changes in the information filed in accordance with 452 CMR 6.04 shall be filed with the OHP within 30 days of said change. (4) The OHP will publish the name and address of each approved UR agent on the DIA web site. (5) All utilization review agents shall comply with the following procedures: (a) All determination letters must identify the treatment guideline and set forth the clinical rationale. An adverse determination letter shall include instructions for the procedure to initiate an appeal of the adverse determination, and set forth the relevant section of the treatment guideline. A copy of the relevant section of the guideline must be provided upon request. The start and end dates for all scheduled health care services shall be clearly documented in the utilization review case note summary and on the determination notice. The date of request and the date of receipt of medical information must be documented by the utilization review agent in the utilization review case record. (b) Notification of all utilization review determinations issued by the utilization review agent shall be communicated to the injured employee/representative and the ordering provider in writing. For prospective reviews, written notice of the determination shall be given within two business days from receipt of the request for approval of treatment and the receipt of all medical information necessary to conduct the review. For concurrent reviews, written notice of the determination shall be given at least one day prior to implementation, i.e., the start date for the ongoing health care service under review, and the receipt of all medical information necessary to conduct the review. For retrospective reviews, written notice of the determination shall be given within 20 business days from receipt of the request for approval of treatment and the receipt of all medical information necessary to conduct the review

116 (c) Any adverse determination of a health care service issued by a utilization review agent shall be issued by a practitioner of the same school as the ordering provider. (d) Utilization review agents shall maintain and make available a written description of the appeal procedure by which the ordering provider or the injured employee may seek review of an adverse determination by the utilization review agent. The appeal procedure, at a minimum, shall provide the following: 1. When an adverse determination is rendered during prospective or concurrent review, and the injured employee and/or the ordering provider believes that the determination warrants immediate appeal, the injured employee or the ordering provider may initiate the appeal via telephone to the utilization review agent with the right to communicate orally with a practitioner of the same school as the ordering provider on an expedited basis. The ordering provider or injured employee should be instructed to follow up with a written request for the appeal. If the injured employee or ordering provider fails to comply, the utilization review agent should send a written confirmation of the appeal request. Said notice of appeal to occur no later than 30 days from the date of receipt of notice of adverse determination. Utilization review agents shall complete the adjudication on an expedited basis and render the determination no later than two business days from the date the appeal is initiated, unless the ordering provider agrees to a different time period. 2. Appeal of retrospective reviews shall be made in writing to the utilization review agent and occur no later than 30 days from the date of receipt of notice of adverse determination. Utilization review agents shall complete the adjudication of a retrospective review/standard appeal no later than 20 days from the date the appeal is filed. (e) Utilization review agents shall make staff available by toll free telephone system at least 40 hours per week between the hours of 9:00 A.M. to 5:00 P.M., EST each business day. (f) Utilization review agents shall have a confidential telephone system capable of accepting and recording incoming telephone calls during other than normal business hours, and the agent shall respond to these calls on the following business day. (g) Utilization review agents shall comply with all applicable laws to protect the confidentiality of medical records and when necessary, obtain a medical release. (h) Practitioners rendering school to school utilization review determinations and medical directors must provide, and attest in writing to providing, patient care for at least eight hours per week. (i) Once an insurer has commenced payment for a work related injury under M.G.L. c. 152, it must issue the employee a card listing the employee name, an identification number assigned to the employee, the name and telephone number of the utilization review agent,

117 (j) and the name of the insurer. The employee must seek approval from the insurer/utilization review agent before receiving medical services. In the case of an emergency, utilization review agents shall allow a minimum of 24 hours after an emergency admission, service, or procedure for an injured employee or injured employee's representative to notify the utilization review agent and request approval for treatment. Initial level reviews must be conducted at the location of the approved utilization review site. (6) After exhaustion of the process set forth in 452 CMR 6.04(5)(d), a party may file a claim or complaint in accordance with 452 CMR 1.07 under the provisions of M.G.L. c. 152, 10. (7) Injured employees may be liable for care subsequent to the adverse determination after they have been notified of that adverse determination. (8) Ancillary Services. 452 CMR 6.00 et seq. concerns the requirements for the performance of utilization review. Should an insurer or self insurer provide ancillary services such as managed care, case management, independent medical exams, or rehabilitation services from vendors who are also approved as utilization review agents, said ancillary services are not to be considered utilization review requirements or expenses. Ancillary services must remain separate and distinct from the utilization review services. Moreover, these ancillary services should not be construed as approved by the OHP by virtue of the OHP's approval of the same vendor to perform utilization review. (9) Each insurer/self insurer is required to inform the OHP of the name of the approved utilization review agent currently responsible for conducting the reviews

118 6.05 Utilization Reporting (1) Providers must use, and insurers must accept, standard forms prescribed by the DIA, based on the most recent Center for Medicare and Medicaid Services forms. (2) The Department may require utilization review agents to provide a sample of up to 100% of all billing records, both inpatient and outpatient, which sample shall be transmitted to the Department of Industrial Accidents so that the Department can implement appropriate utilization oversight. In addition to the standard billing file, for every outpatient service the Department may request information about the insurer, any procedures, and the employer's and provider's identification numbers. For inpatient services, the Department must receive all relevant diagnostic and procedure International Classification of Disease (ICD) codes, Current Procedural Terminology (CPT) and other codes, the length of stay and the cost of any ancillary services. The Department may require both counts of services as well as the amount reimbursed

119 6.06 Treatment Guideline and Review Criteria Development (1) In promulgating these Utilization Review regulations, the Commissioner hereby utilizes the treatment guidelines developed and endorsed by the Health Care Services Board, recognizing that medical treatment cannot be reduced to regulation and that health care providers must be free to exercise their best judgements about the treatment of their patients. (2) The Health Care Services Board will review and update treatment guidelines at least annually. Providers shall consider the treatment guidelines endorsed by the Health Care Services Board and adopted by the Commissioner when caring for injured employees or risk nonpayment. The guidelines should not be construed as including all proper methods of care reasonably directed to obtaining the same results. The ultimate judgement regarding any specific procedure or treatment must be made by the provider in light of all circumstances presented by the injured employee and the needs and resources particular to the locality or facility. The adopted guidelines shall be used by utilization review programs administered by insurers in a form required by the Department, taking into account that appropriate care may vary on a case by case basis

120 6.07 Quality Assessment and Enforcement (1) General Rules for Compliance Enforcement. Pursuant to 452 CMR 6.00 et seq., the Office of Health Policy of the DIA monitors utilization review agents and their programs to ensure full compliance with Massachusetts General Laws and 452 CMR 6.00 et seq. Specific enforcement mechanisms include, but are not limited to, the following: (a) The Commissioner may revoke or refuse to renew a license of a self insurer for the failure of any self insurer to comply with all applicable laws, rules, regulations, orders, and requirements of the Commonwealth. (b) The Commissioner may revoke or refuse to renew the approval of the utilization review agent for failure to comply with all applicable laws, rules, regulations, orders, and requirements of the Commonwealth. (2) The Department of Industrial Accidents will gather data on compliance with the treatment guidelines through reports from insurers and utilization review agents. If a provider's care is demonstrated to be statistically significantly outside a particular guideline, the provider will be informed of this by the Department and educational material regarding the guideline will be transmitted to the provider. On a periodic basis, the provider's utilization patterns will then be reassessed. If the provider remains statistically significantly outside the guideline, the provider will be warned by the Department, educational materials will again be transmitted, and a clinical evaluation performed. If the provider's care is found to remain significantly and frequently outside the guideline, the matter will be transferred to the Commissioner. At the discretion of the Commissioner, the matter may be referred to the Health Care Services Board which may then refer the matter to the appropriate Board of Registration. (3) If the Department finds that the care provided to injured employees through an insurer is more frequently deficient than that provided to other employees in receipt of workers' compensation, the Department will address this issue with the insurer in a manner similar to the one specified in 452 CMR 6.07(2), with the exception that any referral by the Health Care Services Board will be to the Division of Insurance instead of a Board of Registration. (4) The Department shall monitor the utilization review techniques used, and determinations made, by utilization review agents. If the Commissioner receives a complaint from a practitioner, employer, or employee, or has reason to believe that a utilization review agent has been or is engaged in conduct that violates these regulations, the Commissioner shall notify the utilization review agent in writing of the alleged violation. The utilization review agent shall have 20 days from the date the notice is received to respond to the alleged violation. On or after the 20th day, the Commissioner shall render a finding after reviewing all documents submitted by the parties. The Commissioner may also schedule a hearing. If the Commissioner determines that the utilization review agent has violated or is in violation of any law, rule, regulation, order, or requirement, the Commissioner may issue an order requiring the insurer and/or utilization review agent to cease and desist from engaging in the violation(s). The Commissioner may also suspend or revoke the agent's approval to conduct utilization review and may assess a fine

121 If the utilization review agent requests a hearing regarding the findings of the Commissioner, the request must be made in writing within 20 days from receipt of the findings. Upon receipt of the request, the Commissioner shall schedule a hearing to be conducted pursuant to M.G.L. c. 30A. If the Commissioner renders a finding that the utilization agent has violated any law, rule, regulation, order, or requirement, the utilization review agent must inform the adjuster handling the injured employee's claim. (5) A Cease and Desist order may include: (a) a summary of the violation(s); (b) a summary of the facts giving rise to the violation(s); (c) the penalty that the Commissioner intends to apply; and (d) information pertaining to the rights and obligations of the utilization review agent; as well as the procedure for the agent to file a written response or request a hearing. (6) Non compliance Categories include but are not limited to: (a) Failure of an insurer/self insurer to conduct a proper utilization review in accordance with 452 CMR 6.00 et seq. (b) Failure of the utilization review agent to render a written determination to both the injured employee and the ordering provider within the proper time constraints. (c) Failure of the utilization review agent to ensure an appeal level review is conducted by a same school practitioner. (d) Failure of the utilization review agent to issue a written introductory letter within the required time period. (e) Failure of the utilization review agent to use the diagnosis and/or ICD code selected by the ordering provider when determining medical necessity and appropriateness of care. (f) Failure of the utilization review agent to cite the correct, research based treatment guideline when rendering a determination. (g) Failure of the utilization review agent to document clinical rationale to support the guideline. (h) Failure of the utilization review agent to utilize only licensed personnel to determine medical necessity and appropriateness for all health care services under review

122 (i) Failure of the utilization review agent to maintain all required records in the form and manner prescribed by the OHP. (j) Failure to inform the OHP of any material change to the approved utilization review application within 30 days of said change. (k) Failure to adhere to the quality assurance and quality control measures set forth in the utilization review application. (l) Failure to maintain hours of operation between 9:00 A.M. and 5:00 P.M. EST on each business day, and return after hour calls within one business day. (m) Failure to inform the OHP of each site where utilization review is being conducted for Massachusetts claims. (n) Failure of the utilization review agent to comply with audits. (o) Failure of the medical director and school to school reviewers to maintain an active clinical practice of at least eight hours per week. (p) Failure to conduct initial reviews at the approved utilization review site. (7) Quality Assessment Audit Review Procedures. (a) The OHP monitoring of the quality of care rendered to injured employees shall include, but not be limited to: onsite audits; desk audits; and review of patient satisfaction surveys, complaints, and statistical data provided by utilization review agents, insurers, and self insurers. Desk audits shall consist of review of case records selected by the OHP. The OHP may also monitor the performance of providers reimbursed by insurers. (b) Approved utilization review agents shall comply with all requests for onsite and desk audits for continued utilization review approval. (c) Utilization review agents are required to pay all reasonable travel expenses for each onsite audit of the OHP representatives. (d) The OHP will determine the type of audit to be conducted (onsite or desk). The utilization review agent will be notified prior to the scheduled audit date. The agent shall submit a list of all utilization reviews conducted for the period specified by OHP. The OHP will notify the agent which files must be made available for the audit. The agent will make each sample record available, in hard copy, for review on the audit date. (e) If an agent meets the 85% compliance rating score for two consecutive quality assessment audits, the agent's audit schedule may be changed from yearly to every two years. However, if at any time the OHP has reason to believe that the agent is not in full compliance with the laws, rules, regulations, orders, and requirements, by way of complaint

123 or any other means, the agent's approval status may be reviewed and an immediate audit may conducted. (f) If the utilization review agent scores less than 85%, the agent will be placed on a probationary approval status for a period of six months and may be fined up to $ At the end of six months, and after interim audits, the utilization review agent will be informed as to whether or not the agent meets the 85% compliance rate and is approved to continue to conduct utilization review in Massachusetts. If the agent fails to meet the 85% compliance rate, the Commissioner may schedule a hearing to determine whether or not the utilization review agent's approval to conduct utilization review in the Commonwealth should be revoked. (g) The Office of Health Policy, at the direction of the Commissioner, may implement internal OHP policies and procedures at any time to ensure and improve the quality of the utilization review program. (8) Fines. (a) Failure to comply with all applicable rules, regulations, orders and requirements of the OHP may result in a fine of up to $ per violation. (b) Should the utilization review agent violate a cease and desist order within one year from the issuance date, additional fines may be assessed based on the violation. Penalties shall be additional fines of up to $ per occurrence, or may result in the Commissioner revoking the utilization review agent's continued approval

124 Addenda Tennessee Requirements DEFINITIONS. The following definitions are for the purpose of these Utilization Review Rules, Chapter : (1) Act means the Tennessee Workers Compensation Act, T.C.A , et seq., as amended. (2) Administrator means the chief administrative officer of the Workers Compensation Division of the Tennessee Department of Labor and Workforce Development, or the Administrator s designee. (3) Advisory Medical Practitioner means an actively Tennessee-licensed practitioner, who is board certified, who is in good standing, who is in the same or similar general specialty as the recommending authorized treating physician, and who makes utilization review determinations for the utilization review agent or the Department. (4) Authorized Treating Physician means the practitioner chosen from the panel required by T.C.A or a practitioner referred to by the practitioner chosen from the panel required by T.C.A , as appropriate. Authorized Treating Physician shall also include any other medical professional recognized and authorized by the employer or designated by the Division to treat any injured employee for a work-related injury or condition. (5) Business day means any day upon which the Workers Compensation Division is open for business. (6) Commissioner means the Commissioner of the Tennessee Department of Labor and Workforce Development, the Commissioner s Designee, or an agency member appointed by the Commissioner. (7) Consultation fee means a fee for a practitioner who provides consultation services to the Division for the purpose of determining an appeal pursuant to this Chapter. Such fee shall be prescribed by the Commissioner and posted on the division s website. Such fee shall not increase or decrease except after thirty (30) calendar days from the date a notice of increase or decrease is posted on the Division s website. (8) Contractor means an independent utilization review organization not owned by or affiliated with any carrier authorized to write workers compensation insurance in the state of Tennessee with which the Commissioner has contracted to provide utilization review, including peer review, for the Division, as referred to in T.C.A (9) Department means the Tennessee Department of Labor and Workforce Development

125 (10) Division means the Workers Compensation Division of the Tennessee Department of Labor and Workforce Development. (11) Employee means an employee as defined in T.C.A , but also includes the employee s representative or legal counsel. (12) Employer means an employer as defined in T.C.A , but also includes an employer s insurer, third party administrator, self-insured employers, self-insured pools and trusts, as well as the employer s representative or legal counsel, as applicable. (13) Health care provider includes, but is not limited to, the following: licensed individual, chiropractor, dentist, physical therapist, physician, surgeon, group of practitioners, hospital, free standing surgical outpatient facility, health maintenance organization, industrial or other clinic, occupational healthcare center, home health agency, visiting nursing association, laboratory, medical supply company, community mental health center, and any other facility or entity providing treatment or health care services for a work-related injury (14) Inpatient services means services rendered to a person who is formally admitted to a hospital and whose length of stay exceeds twenty-three (23) hours. (15) Medical Director means the Medical Director of the Division appointed by the Commissioner pursuant to T.C.A , or the Medical Director s designee chosen to act on behalf of the Medical Director. (16) Medical necessity means health care services that a practitioner, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are in accordance with generally accepted standards of medical practice. (17) Outpatient services means a service provided by the following, but not limited to, types of facilities: physicians offices and clinics, hospital emergency rooms, hospital outpatient facilities, community mental health centers, outpatient psychiatric hospitals, outpatient psychiatric units, and freestanding surgical outpatient facilities also known as ambulatory surgical centers. Outpatient services also include hospital admissions for a patient whose length of stay does not exceed twenty-three (23) hours. (18) Parties means the employee, authorized treating physician and employer as those terms are defined herein. (19) Practitioner means a person currently licensed in good standing to practice as a doctor of medicine, doctor of osteopathy, doctor of chiropractic, or doctor of dental medicine or dental surgery. (20) Recommended treatment means the recommendation of the authorized treating physician

126 to perform or refer treatments, procedures, surgeries, and/or admissions in either an inpatient or outpatient setting. Recommended treatment shall also mean emergency treatments, procedures, surgeries, and/or admissions when retrospective review is performed. (21) Records means medical records and reports regarding an employee s claim for workers compensation benefits. Records include electronic imaging of such documents. (22) Standard appeal fee means a fee charged by the Division for the purpose of determining an appeal pursuant to this Chapter. Such fee shall be prescribed by the Commissioner and posted on the Division s website. Such fee shall not increase or decrease except after thirty (30) calendar days from the date a notice of increase or decrease is posted on the Division s website. (23) Utilization review means evaluating the quality and appropriateness of health care or health care services in workers compensation cases pursuant to the timeframes, procedures, and requirements of this Chapter, , and as defined in T.C.A The employer shall be responsible for all costs associated with utilization review and shall in no event obligate the employee, health care provider or Department to pay for such services. (24) Utilization review agent means an individual or entity authorized to do business in Tennessee, having certified to the Commissioner of Commerce and Insurance pursuant to T.C.A , et seq., and registered with the Division

127 UTILIZATION REVIEW SYSTEM. (1) This Chapter shall apply to all recommended treatments for work-related injuries or conditions whenever the recommendation is made after this Chapter, as amended, becomes effective. (2) Employers shall establish and maintain a system of utilization review. An employer may choose to provide utilization review services itself, through its insurer or through a third party administrator. Whenever utilization review is conducted, whether mandatory under this Chapter, , or not, such utilization review shall be conducted in complete conformity with this Chapter. Failure to comply with this Chapter in any way may subject the employer and utilization review agent to sanctions and/or civil penalties as set forth in Rule The Medical Director or a workers compensation specialist may determine whether a utilization review was conducted in conformity with this Chapter and may determine that a utilization review is void. (3) The Commissioner may provide or contract for certain utilization review services with a Contractor. The Contractor may provide any service allowed by T.C.A , including, but not limited to, reviewing utilization review services and providing peer review. The parties shall cooperate and provide any necessary medical information to the Contractor when requested, which shall not constitute a waiver of any applicable privilege or confidentiality. (4) Any organization conducting utilization review for workers compensation cases pursuant to this Chapter shall provide to the Administrator copies of any information provided to the Commissioner of Commerce and Insurance pursuant to T.C.A Any organization conducting utilization review for workers compensation cases must also register with the Division on a form prescribed by the Administrator. Failure to certify to the Commissioner of Commerce and Insurance and be registered with the Division prior to performing utilization review services may result in sanctions and/or civil penalties pursuant to Rule of this Chapter. (5) Subject to any applicable requirements of law concerning confidentiality of records, a utilization review agent shall provide the Division, including the Medical Director, with any appropriate utilization review records or permit the Division to inspect, review, or copy such records in a reasonable manner. The Division will maintain any required confidentiality of any personally identifying information concerning employees claiming workers compensation benefits. Provision of these records pursuant to this rule shall not constitute a waiver of any applicable privilege or confidentiality. (6) In no event shall an individual concurrently perform case management services, as set forth in Chapter , and utilization review with regard to a single claim of work-related injury. (7) Billing and payment for any medical services provided in conjunction with this Chapter shall be subject, as applicable, to the Division s Medical Cost Containment Program, Medical Fee Schedule, or In-Patient Hospital Fee Schedule rules contained in Chapters , , and , respectively

128 UTILIZATION REVIEW REQUIREMENTS. (1) In any case in which utilization review is undertaken, the utilization review agent shall make an objective evaluation of the recommended treatment as it relates to the employee s condition and render a determination concerning the medical necessity of the recommended treatment. A utilization review agent may contact the authorized treating physician regarding the recommended treatment pursuant to applicable law; provided that such contact shall not constitute a waiver of any other applicable privilege or confidentiality. (2) Upon initiation of utilization review, the authorized treating physician shall submit all necessary information to the utilization review agent and shall certify that the information is a complete copy of the health care provider s records and reports that are necessary for utilization review. The authorized treating physician shall also include the reason(s) for the necessity of the recommended treatment in such records and reports. The employer, or other payer, shall reimburse the authorized treating physician for the costs of copying and transmitting such records; provided that the costs do not exceed the amounts prescribed by T.C.A If a dispute arises as to the necessity of information, then the parties shall proceed as set forth in Rule (5). (3) Upon receipt of all necessary information, the initial utilization review decision may be determined by a licensed registered nurse whenever the recommended treatment is being approved. For all denials, the utilization review decision shall be determined by an advisory medical practitioner and communicated to the parties in a written utilization review report

129 CONTENTS OF UTILIZATION REVIEW REPORT. (1) The utilization review agent shall communicate its determination to the parties within the timeframe established in Rule If the utilization review determination is a denial of a recommended treatment, then the utilization review agent shall submit a written utilization review report in conformity with the requirements of subsection (2) of this Rule. If the utilization review determination is an approval of a recommended treatment, then the utilization review agent shall submit written documentation of the determination; provided that the written documentation is not required to be a utilization review report in conformity with the requirements of subsection (2) of this Rule. A utilization review report and other written documentation may be communicated through electronic means when available. (2) The utilization review report shall adhere to the following requirements: (a) The utilization review agent shall only consider the medical necessity, appropriateness, efficiency, and quality of the recommended treatment for the employee s condition. (b) Whenever a utilization review agent determines that the recommended treatment will be denied, the utilization review report must contain specific and detailed reasons for the denial. (c) The utilization review agent shall also include the name, address, phone number and qualifications of the advisory medical practitioner making a denial determination. (d) All utilization review reports that deny a recommended treatment shall include an appeal form prescribed by the Division. The utilization review agent shall transmit a copy of the utilization review report and appeal form to the authorized treating physician, employee, and employer. Upon request, the utilization review agent shall transmit any utilization review report to the Division. Failure to include the appeal form in the utilization review report and transmit such to all parties may result in sanctions and/or civil penalties pursuant to Rule of this Chapter

130 MANDATORY UTILIZATION REVIEW. (1) The parties are required to participate in utilization review under this Chapter whenever a dispute arises as to the medical necessity of a recommended treatment. (2) Utilization review is required to be performed pursuant to the requirements of this Chapter whenever it is mandated by T.C.A or the Division s Medical Cost Containment Program, Medical Fee Schedule, or In-Patient Hospital Fee Schedule rules contained in Chapters , , and , respectively

131 TIME REQUIREMENTS. (1) If a recommended treatment requires utilization review, then an employer shall submit the case to its utilization review agent within three (3) business days of the authorized treating physician s notification of the recommended treatment, subject to subsection (5) of this Rule. The authorized treating physician s notification of the recommended treatment to the employer shall, at a minimum, be in a form that confirms transmission by showing the time and date of receipt (e.g., facsimile). The employer shall notify all parties upon submitting the case to its utilization review agent, and shall also notify any workers compensation specialist assigned to the claim. If the employer fails to comply with this subsection, then the employer may be subject to sanctions and/or civil penalties pursuant to Rule of this Chapter. (2) The utilization review agent shall render the determination and communicate the determination in writing to the authorized treating physician, employee and employer within seven (7) business days of receipt of the case from the employer, subject to subsection (5) of this Rule. If a denial, the utilization review report shall list all records and supplemental material reviewed by the utilization review agent. Upon request, the authorized treating physician or employee may obtain copies of any such records and supplemental material reviewed by the utilization review agent. The utilization review report shall also include an appeal form prescribed by the Division on which the utilization review agent shall identify the state file number associated with the claim for which treatment is being recommended, if any, and shall identify the utilization review agent s certification number issued by the Division. If the utilization review agent fails to comply with this subsection, then the utilization review agent may be subject to sanctions and/or civil penalties pursuant to Rule of this Chapter. (3) If a denial of the recommended treatment is appealed, then the utilization review agent shall send a copy of the utilization review report and all records reviewed by the utilization review agent to the Division upon request. (4) An approval of a recommended treatment by the employer s utilization review agent shall be final and binding on the parties for administrative purposes. (5) When there is a dispute over a request for information, the following timeframes shall apply: (a) If the employer or utilization review agent does not possess all necessary information in order to dispute the recommended treatment or render the utilization review determination, then it shall immediately make a written request for such information to the authorized treating physician, who shall comply with the written request within five (5) business days of receipt of the written request. The time requirements in subsections (1)-(2) of this Rule shall be tolled until the employer or utilization review agent receives the necessary information or until the timeframe set forth in the preceding sentence expires, whichever occurs first. (b) Denials for inadequate information may be appealed pursuant to Rule ,

132 at which time the authorized treating physician shall submit all information deemed to be necessary by the Division. If the Division finds that the employer s or utilization review agent s request did not pertain to necessary information, then the employer or utilization review agent may be subject to sanctions and/or civil penalties as set forth in Rule , at the discretion of the Commissioner. In addition, if an authorized treating physician fails to cooperate and timely furnish all necessary information, records and documentation to an employer or utilization review agent, then the authorized treating physician may be subject to sanctions and/or civil penalties as set forth in Rule , at the discretion of the Commissioner. (6) Employer s obligations upon receipt of utilization review determination: (a) Within three (3) business days of receiving a utilization review determination that denies the recommended treatment, the employer shall give written notification to the employee and authorized treating physician as to whether the employer will authorize any of the recommended treatments that were denied by the utilization review agent and what, if any, conditions shall apply to such authorization. (b) Within three (3) business days of receiving a utilization review determination that is either an approval or denial, the employer shall forward such determination to any workers compensation specialist assigned to the claim. The employer shall also forward the notification described in subsection (6)(a) above, if applicable

133 APPEALS OF UTILIZATION REVIEW DECISIONS. (1) Every denial of a recommended treatment shall be accompanied by a form prescribed by the Division that informs the employee and authorized treating physician how to request an appeal with the Division. The employee or authorized treating physician shall have thirty (30) calendar days from receipt to request an appeal with the Division. (2) Upon receipt of an appeal request by an employee or authorized treating physician: (a) The Division shall conduct the utilization review appeal. The Division may contact the authorized treating physician for peer review purposes. The Division shall determine the medical necessity of the recommended treatment within twenty-five (25) business days after receipt of all necessary information. The Division shall then transmit such determination to the authorized treating physician, employee, and employer. The determination of the Division is final for administrative purposes, subject to the provisions of subsections (3)-(5) of this Rule. (b) If any information necessary for the determination of the appeal is not within the possession of the Division, then the timeframe in subsection (a) shall be tolled until all such information is submitted and may subject any party withholding such information to sanctions and/or civil penalties as set forth in Rule , at the discretion of the Commissioner. (c) The employer shall remit the standard appeal fee and/or the consultation fee to the Division. If the applicable fee is not received within ten (10) business days of the issuance of the Division s determination, a late fee of 10% of the applicable fee per day shall accrue until payment is received. (3) If the determination of the Division is an approval of the recommended treatment, then a workers compensation specialist shall issue an order for medical benefits. The penalty provisions of T.C.A (d) shall apply to orders issued pursuant to this subsection (3). (4) If the determination of the Division is a denial of the recommended treatment, then the parties may file a Request for Benefit Review Conference or may request a waiver of the benefit review conference requirement, as applicable. (5) Notwithstanding any other provision to the contrary, if the parties agree on a recommended treatment after the employer s utilization review agent has denied such, then the parties may, by joint agreement, override the determination of the employer s utilization review agent and approve the recommended treatment. Such approval by agreement shall terminate any appeal to the Division and no fee shall be required of the employer for any such appeal that has yet to be determined by the Division

134 UTILIZATION REVIEW FORMS. (1) All utilization review agents must file the Utilization Review Notification form (Form C-35) immediately upon initiation of utilization review services on an employee s workers compensation claim. Only one form is necessary for each claim. (2) All utilization review agents must file the Utilization Review Closure form (Form C-36/C- 37) immediately following the conclusion of utilization review services on an employee s workers compensation claim. Only one form is necessary for each claim. (3) All utilization review agents must file an annual report on a form prescribed by the Division and accessible through the Division s website

135 SUBCONTRACTORS. (1) A utilization review agent shall be responsible for any advisory medical practitioner(s) and registered nurse(s) with whom the utilization review agent subcontracts to perform utilization reviews. If a subcontractor performs a utilization review in accordance with the requirements of this Chapter, then the utilization review shall be treated as if performed by the contracting utilization review agent. A utilization review agent shall be liable for all sanctions and/or civil penalties contained in this Chapter whenever its subcontractor violates any provision contained herein. (2) A utilization review agent may only subcontract with an advisory medical practitioner as defined in Rule (3) or registered nurse. All other subcontracting for utilization review services is prohibited and will result in the invalidity of such utilization review determination

136 SANCTIONS AND CIVIL PENALTIES. (1) Failure by an employer, insurer, third party administrator, or utilization review agent to comply with any requirement in this Chapter, , including but not limited to applying utilization review when required and complying with the timeframes for utilization review, shall subject such party to a penalty of not less than one hundred dollars ($100.00) nor more than one thousand dollars ($1,000.00) per violation at the discretion of the Commissioner. The Division may also institute a temporary or permanent suspension of the right to perform utilization review services for workers compensation claims, if the utilization review agent has established a pattern of violations. (2) A health care provider is subject to the penalties enumerated in T.C.A (e) as if set forth fully herein. (3) The penalty for failure to timely file the Form C-35 or Form C-36/C-37 in accordance with Rule is twenty-five dollars ($25) for each fifteen (15) calendar days past the initiation or conclusion of utilization review services, as applicable, per violation. The penalty for failure to file the annual report in accordance with Rule is twenty-five dollars ($25) for each fifteen (15) calendar days past the final date for filing the annual report

137 ISSUANCE AND APPEAL OF SANCTIONS AND CIVIL PENALTY ASSESSMENTS. (1) An agency decision assessing sanctions and/or civil penalties shall be communicated to the party to whom the decision is issued, and the party to whom it is issued shall have fifteen (15) calendar days from the date of issuance to either appeal the decision pursuant to the procedures provided for under the Uniform Administrative Procedures Act, T.C.A , et seq., or to pay the assessed penalties to the Department or otherwise comply with the decision. (2) In order for a party to appeal an agency decision assessing sanctions and/or civil penalties, the party must file a petition with the Commissioner within fifteen (15) calendar days of the issuance of the decision. This petition shall be considered a request for a contested case hearing within the Department pursuant to the Uniform Administrative Procedures Act, T.C.A , et seq., and the procedural rules of Chapter are incorporated as if set forth fully herein. The Department is authorized to conduct the hearing pursuant to T.C.A (3) If the agency decision assessing sanctions and/or civil penalties is not appealed within fifteen (15) calendar days of its issuance, the decision shall become a final order of the Department not subject to further review

138 Addenda Utah Requirements R Utilization Review Standards. A. As used in this subsection: 1. "Payor" means a workers' compensation insurance carrier, a self-insured employer, third-party administrator, uninsured employer or the Uninsured Employers' Fund, which is responsible for payment of the workers' compensation claim. 2. "Health Care Provider" means a provider of medical services, including an individual provider, a health-service plan, a health-care organization, or a preferred-provider organization. 3. "Request for Authorization" means any request by a physician for assurance that appropriate payment will be made for a course of proposed medical treatment, including surgery or hospitalization, or any diagnostic studies beyond plain X-rays. 4. "Utilization Review," as authorized in Section 34A-2-111, is a process used to manage medical costs, improve patient care, and enhance decision-making. Utilization review includes, but is not limited to, the review of requests for authorization to treat, and the review of bills, for the purpose of determining whether the medical services provided were or would be necessary, to treat the effects of the injury/illness. Utilization review does not include bill review for the purpose of determining whether the medical services rendered were accurately billed. Nor does it include any system, program, or activity in connection with making decisions concerning whether a person has sustained an injury or illness which is compensable under Section 34A-2 or 34A "Reasonable Attempt" is defined as at least two phone calls and a fax, or three phone calls, within five business days from date of the payor's receipt of the physician's request for review. B. Any utilization review system shall establish an appeals process which utilizes a physician(s) for a final decision by the insurer, should an initial review decision be contested. The payor may establish levels of review that meet the following criteria: 1. Level I--Initial Request and Review. A payor may use medical or non-medical personnel to initially apply medically-based criteria to a request for authorization for payment of a specific treatment. The treating physician must send all the necessary documentation for the payor to make a decision regarding the treatment recommended. The payor must then notify the physician within five business days of the request for authorization of payment for the treatment, by a method which provides certification of transmission of the document, of either an acceptance or a denial of the request. A denial for authorization of payment for a recommended treatment utilizing the Commission's form, Form 223, must be sent to the provider with the criteria used in making the determination to deny payment for the treatment. A copy of the denial must also be mailed to the claimant. Level I--Request and Review does not include authorization requests for services billed from the Restorative section of the Resource-Based Relative Value Scale (RBRVS). Requests for authorization for restorative services are governed by rule R (B). 2. Level II--Review. A physician, who has been denied authorization of payment for treatment, or has received no response within five business days from the request for authorization for payment at Level I review, may request a physician's review by sending the completed portion of the Commission form 223 to the payor. Such a request for review may be filed by any physician who has been denied authorization for payment for restorative services beyond the initial eight visits as authorized by Rule R (B). The requesting physician must include the times and days that he/she is available to discuss the case with the reviewing physician, and must be reasonably available during normal business hours. The payor's physician representative must complete the review within five business days of the treating physician's request for review. Before the insurer's physician representative may issue a denial of an authorization for payment to treat, a reasonable effort must have made to contact the requesting treating physician to discuss the differing aspects of

139 the case. Failure by the payor to respond within five business days, by a method which provides certification of transmission, to a denial for authorization for payment for treatment, shall constitute an authorization for payment of the treatment. The payor's denial to pay for the recommended treatment must be issued on Commission's form 223, and the denial must be accompanied by the criteria that was used in making the decision to deny authorization, along with the name and speciality of the reviewing physician. The denial to authorize payment for treatment must then be sent to the physician, the claimant, and the Commission. The payor shall notify the Commission if an additional five days is needed in order to contact the treating physician or to review the case. An additional extension of time may be requested from the Commission to accommodate highly unusual circumstances or particularly difficult cases. C. Upon receipt of denial of authorization for payment for medical treatment at Level II, the Commission will facilitate, upon the request of the claimant, the final disposition of the case. If the parties agree, the medical dispute may be resolved by the Commission through binding mediation or medical review. If there is not agreement among the parties, the Commission will resolve the dispute through formal adjudication. The payor shall be responsible for sending the claimant the Commission appeals information when the denial for authorization for payment for medical treatment is sent to the claimant. D. If the medical treatment requested is not an emergency, and treatment is rendered by the physician after, receiving notice of the utilization standards encompassed in this rule, the following shall apply: 1. The Commission shall, if the disputed medical treatment is ultimately determined to be compensable as an expense necessary to treat the industrial injury or occupational disease, order that the physician be reimbursed at only 75% of the of the amount otherwise payable had appropriate authorization been timely obtained. The injured worker shall not be liable for any additional payment to the physician above the 75%. 2. Neither the worker's employer or its workers' compensation insurer shall be liable for any portion of the cost of disputed medical treatment, if that treatment is ultimately determined not to be compensable as an expense necessary to treat an industrial injury or occupational disease. 3. A worker may become liable for the cost of the disputed medical treatment, if that treatment is ultimately determined not to be compensable as an expense necessary to treat the industrial injury or occupational disease. 4. Except for any co-pays or deductibles under the worker's health insurance plan, the penalty provision in D(1) and D(3) shall not apply if the physician performs the medical treatment in question, having been preauthorized in writing to do the same by a health insurer or other non-worker's compensation insurance payor. 5. The penalty provisions in D(1) shall not apply to medical treatment rendered in emergency situations, which are defined as a threat to life or limb. 6. The Commission shall notify a physician, in writing, of reported violations of this rule. Repeated violations of this rule by a physician may result in a report from the Commission to the Department of Commerce, Division of Occupational/Professional Licensing

140 Confidentiality CID Management Policy No Revision: 3.3 Revision Date: 6/16/2009 Page 1 of 3 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which confidentiality of all information shall be maintained. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /15/2008 Revised Revision /12/2009 Revised Revision /16/2009 Revised Revision /08/2010 Reviewed Revision /26/2011 Reviewed Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all CID employees and contractors who perform utilization management operations, and all others who serve on committees or boards. 4.0 Policy The policy of CID Management is to handle all information in a manner that that ensures the privacy and security of the records. All information that identifies a specific individual shall be kept confidential and shall not be disclosed to any individual or organization outside of disclosures permitted or required by law. The release or re-release of confidential information to unauthorized persons is strictly prohibited. 5.0 Definitions Definitions of terms are set forth in Policy Procedures

141 6.1 All CID employees and contractors, who perform utilization management operations, as well as all committee members and board members, shall sign a CID / Business Associate HIPAA Agreement. 6.2 All CID employees and contractors, who perform utilization management operations, as well as all committee members and board members, shall review this policy. 6.3 All CID employees and contractors, who respond to communications, shall undergo training regarding this policy, these procedures and their implementation. 6.4 All information that identifies a specific individual shall be kept confidential and shall not be disclosed to any individual or organization outside of disclosures permitted or required by law. 6.5 To the extent permitted by state and federal law, the release of information on a specific review is restricted to the following people: CID employee s or contractors who require the information to perform utilization management operations Patient Patient s legal counsel Claims administrator Client appointed personnel specified by the client as being involved in the claim and/or review (e.g. nurse case manager) Defense attorney Requesting physician, or their office staff Attending physician, or their office staff Secondary physicians, or their office staff Non-physician provider of goods and/or services 6.6 If a CID employee or contractor receives a request for information regarding a specific claim or review, they shall verify that the requestor is a party identified in point 6.5 of this policy. If it can not be established that the requestor is a party identified in point 6.5 of this policy, the requestor shall be referred to the claims administrator for further help. 6.7 The release of patient information, such as social security number, date of birth, contact information that does not specifically bear upon the utilization management determination shall be prohibited. If any person requests this information, the requestor shall be referred to the claim administrator for further help. 6.8 The release of provider information, such as federal tax id number or contact information, which does not specifically bear upon the utilization management determination, shall only be accessible to the client for purposes of billing and bill review. Any other release of this information shall be prohibited. If any person requests this information, the requestor shall be referred to the claim administrator for further help

142 6.9 In the event that CID publishes data, such as quality review studies or performance tracking, in every instance where such publication includes data which identifies a particular physician or health care provider, the physician or health care provider shall be provided written notice of the publication

143 Addendum State of Texas 1.0 CID will provide to the Texas Department of Insurance (TDI), upon request, individual medical records or other confidential information to enable the TDI to determine compliance with the Texas statutes and rules. 2.0 If a CID employee or contractor receives a written request from an individual for access to recorded personal information concerning that individual, CID will within 10 business days from the date that CID received the request: 2.1 Inform the individual in writing of the nature and substance of the recorded personal information; and 2.2 Allow the individual, at the individual s discretion, to: View and copy, in person, the recorded personal information concerning that individual; or Obtain a copy of the information by mail. 2.3 If the information is in a coded form, CID will provide, in writing, an accurate translation of the information, in plain language. 2.4 Charges for providing a copy of information requested under this section shall not exceed ten cents per page and may not include any costs that are otherwise recouped as part of the charge for utilization review. 2.5 Personal information shall include, at a minimum, name, address, phone number, social security number, and financial information. 3.0 CID personnel and reviewers may not disclose individual medical records, personal information, or other confidential information about a patient obtained in the performance of utilization review without the patient's prior written consent or except as otherwise required by law. 3.1 If the prior written consent is submitted by anyone other than the patient who is the subject of the personal or confidential information requested, the consent must be dated; and contain the patient's signature. 3.2 The patient's signature must have been obtained one year or less before the date the disclosure is sought or the consent is invalid. 4.0 To assure confidentiality, CID personnel and reviewers must, when contacting a doctor's office or hospital, provide CID s certification number, the caller's name, and professional qualifications to the provider's named utilization review representative in the health care provider's office. 5.0 Upon request by the provider, the CID staff shall present written documentation that it is acting as an agent of the insurance carrier for the relevant injured employee. 6.0 Medical records and injured employee specific information shall be maintained by the utilization review agent in a secure area with access limited to essential personnel only. 7.0 Information generated and obtained by the utilization review agents in the course of utilization review shall be retained for at least two years from the date of the final decision in the utilization review. 8.0 Documents in the custody of CID that contain confidential injured employee information or doctor or other health care provider financial data shall be destroyed by a method which induces complete destruction of the information when CID determines the information is no longer needed

144 Grievances CID Management Policy No Revision: 3.2 Revision Date: 3/16/2011 Page 1 of 3 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which grievances shall be handled. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /09/2008 Revised Revision /24/2009 Revised Revision /08/2010 Reviewed Revision /28/2011 Revised Revision /16/2011 Revised Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all CID employees and contractors who perform utilization management operations. This policy further affects all stakeholders on any services rendered by CID utilization management. 4.0 Policy The policy of CID Management is to formally investigate all complaints and grievances filed against any CID employee or contractor who performs utilization management operations, or against the CID utilization management process itself. All clinical-related and determinationrelated issues shall be addressed by the Appeals Consideration policy. All non-clinicalrelated and non-determination-related grievance issues shall be addressed by this policy. 5.0 Definitions Definitions of terms are set forth in Policy Procedures

145 6.1 The Clinical Director shall ensure that the Grievance Process is outlined on all determination letters. 6.2 The Clinical Director shall ensure that the Grievance Process is posted on the CID webpage at The Clinical Director shall ensure that all non-clinical administrative staff members who are required to interact with outside parties are trained on, and can answer questions related to, the grievance process, including providing contact information for appropriate regulatory and/or investigational agencies. 6.4 CID encourages all stakeholders to resolve individual inquires and problems without the initiation of a formal grievance. Any party who has an inquiry or complaint may contact CID at for verbal resolution. 6.5 In the event that a complaint may not be settled at the informal level and the party is still dissatisfied, he/she will be advised to file a formal grievance. 6.6 Grievances must be submitted within one year of occurrence and shall be submitted in writing. The written grievance shall contain the following information: The individual s name, address and telephone number A summary of the grievance, any previous contact made with CID, and a description of the relief sought The individuals signature The date the grievance was signed. 6.7 The written grievance shall be mailed to CID. The mailing address for this purpose shall be provided on the grievance form and on adverse determination letters. The grievance form shall be available to the public via CID s public web site. 6.8 Upon receipt, the written grievance shall be forwarded to the chair of the Grievance Committee who shall acknowledge the receipt of the grievance within 5 business days. 6.9 The Grievance Committee shall investigate the grievance and shall notify the party of the final decision in writing within 30 calendar days Should the Grievance Committee determine that any action is required as a result of the grievance, they shall communicate this determination to the Clinical Director who shall be responsible for ensuring the follow up action occurs

146 6.11 All complaints and grievances shall be reported by the Clinical Director, at the quarterly meetings of the QAQC Committee

147 Addendum State of Texas 1.0 By March 1st of each year, CID will submit to the commissioner, a summary report of all complaints received during the preceding calendar year in the required format. 2.0 A complaint may be oral or written. 3.0 A complaint will be accepted from the injured worker, their representative or the health care provider. 4.0 If a complaint is received concerning an appeal of an adverse determination, the Texas appeal/reconsideration standard procedure (CID Policy 3400, Texas Addendum) will be followed including written response to the complainant via the appeal determination letter within 30 days. 5.0 If a complaint is received outside of the appeal/reconsideration process, the standard CID complaint process will be followed. 5.1 In addition to the standard process, the Director of Production or their designee will provide a written response to the complainant within 30 days of receipt of the complaint. 5.2 The Director of Production or their designee will ensure that the information needed to complete the annual complaint and URA summary report is tracked and maintained. 6.0 CID will maintain a record of each complaint until the 3rd anniversary of the date the complainant filed the complaint

148 Non-Clinical Administrative Staff Credentialing CID Management Policy No Revision: 3.0 Revision Date: 6/5/07 Page 1 of 3 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which non-clinical administrative staff employed by CID to perform utilization management operations are credentialed. 2.0 Revision History Revision /15/2006 New Policy & Form/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /16/2009 Reviewed Revision /08/2010 Reviewed Revision /27/2011 Reviewed Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all non-clinical administrative staff members employed by CID to perform utilization management operations. 4.0 Policy The policy of CID Management is to perform credentialing on all non-clinical administrative staff members upon initial hiring. The credentialing may include, but is not limited to, reference checks. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 Upon interviewing prospective employees or contractors, CID shall require the candidates to list a minimum of two references

149 6.2 If, following the interview process, CID has determined that the candidate is a viable choice for the position, prior to making a job offer, a member of the interview team may contact the references listed by the candidate. 6.3 The CID interview team member calling for reference check shall complete the attached form, Telephone Reference Check Non-Clinical Administrative Staff, for each reference contacted. 6.4 The completed Telephone Reference Check Non-Clinical Administrative Staff form shall be added to the employee s personnel folder if they are hired

150 CID Management Telephone Reference Check - Non-Clinical Administrative Staff Applicant s Name: Person Contacted: Title: Company Contacted: Phone: My name is and I work at CID Management. I am calling to perform a reference check for who has applied for a position with us. He/She has listed you as a reference. Is this a good time to speak with you? [if no, offer to call back at a convenient time or provide your number and allow them to call you back] 1. What was your relationship to: 2. What were his/her dates of employment? Start date End Date 3. What was the nature of his/her job with your organization? 4. What did you think of his/her work? 5. What were his/her strong points? 6. What were his/her weak points? 7. How well did he/she work with co-workers? 8. Please comment on his/her: a. Attitude b. Dependability c. Quality/Quantity of work d. Degree of supervision needed e. Leadership 9. Why did he/she leave the position? 10. Would you re-employ? If no, why not? 11. Is there anything else you would like to add regarding his/her employment or job performance? Signature: Date:

151 Non-Clinical Administrative Staff Initial Paperwork CID Management Policy No Revision: 3.0 Revision Date: 6/5/07 Page 1 of 2 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines for paperwork required to be signed by non-clinical administrative staff prior to being employed with CID to perform utilization management operations. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /16/2009 Reviewed Revision /08/2010 Reviewed Revision /01/2011 Reviewed Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all non-clinical administrative staff members employed by CID to perform utilization management operations. 4.0 Policy The policy of CID Management is to require the following items to be completed by all nonclinical administrative staff members employed by CID to perform utilization management operations prior to commencement of the employment relationship: 4.1 Employment Application 4.2 Non-clinical administrative staff contract 4.3 Non-disclosure agreement 4.4 CID/business associate HIPAA agreement

152 4.5 Conflict of interest form 4.6 W9 or W2, as applicable 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 Prior to interview, all candidates must complete an employment application form. 6.2 Upon official offer of an employment position, CID shall provide the candidate with a copy of, and shall review, explain and answer any questions from the candidate regarding the following documents: Non-clinical administrative staff contract Non-disclosure agreement CID/business associate HIPAA agreement Conflict of interest form W9 6.3 The candidate shall have all the time they feel they require to review the documents and ask questions of CID. 6.4 Upon receipt of all completed documents listed in section 6.2, the employee shall begin employment at CID

153 Non-Clinical Administrative Staff Training CID Management Policy No Revision: 4.0 Revision Date: 1/29/2008 Page 1 of 3 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines for training provided to non-clinical administrative staff employed with CID to perform utilization management operations. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /24/2006 Addition of training in URAC standards Revision /26/2006 Revised Revision /05/2007 Revised Revision /29/2008 Revised Revision /16/2009 Reviewed Revision /08/2010 Reviewed Revision /01/2011 Reviewed Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all non-clinical administrative staff members employed by CID to perform utilization management operations. 4.0 Policy The policy of CID Management is to provide non-clinical administrative staff, employed by CID to perform utilization management operations, with the following training sessions: 4.1 Introduction to CID 4.2 Introduction to workers compensation 4.3 Introduction to utilization management Overview of utilization management

154 4.3.2 Labor code, regulations, and case law regarding utilization management CID s utilization management process URAC utilization management standards 4.4 Conflict of interest policies and procedures 4.5 Confidentiality policies and procedures 4.6 Job specific training, 4.7 Periodic Training Updates as required including: Changes to the CID utilization management process Changes to labor code, regulations, or case law regarding utilization management 4.8 Training on identification and prevention of fraud and abuse, as appropriate to job functions 4.9 Re-Training on an annual basis. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 Upon hire, the non-clinical administrative staff employee s supervisor shall schedule the following training sessions for the new non-clinical administrative staff employee: Introduction to CID Introduction to workers compensation Introduction to utilization management Overview of utilization management Labor code, regulations, and case law regarding utilization management CID s utilization management process URAC utilization management standards

155 6.1.4 Conflict of interest policies and procedures Confidentiality policies and procedures Job specific training Identification of fraud and abuse 6.2 Completion of each training session in section 6.1 shall be logged into the nonclinical administrative staff employee s personnel file by the employee s supervisor. 6.3 As needed, the employee s supervisor shall schedule periodic training updates for all non-clinical administrative staff employees. 6.4 Completion of periodic training updates may be logged into the non-clinical administrative staff employee s personnel file at the discretion of the employee s supervisor. 6.5 If the employee s supervisor notes an area of performance in which the non-clinical administrative staff employee is not adhering to CID s policies and procedures, or in which the job duties are being performed in an unacceptable fashion, the supervisor shall schedule re-training. The reason for the re-training shall be logged into the nonclinical administrative staff employee s personnel file by the employee s supervisor. 6.6 Completion of each re-training session shall be logged into the non-clinical administrative staff employee s personnel file by the employee s supervisor. 6.7 If QAQC committee notes an area of performance in which the non-clinical administrative staff employee is not adhering to CID s policies and procedures, or in which the job duties are being performed in an unacceptable fashion, they shall communicate this to the employee and the employee s supervisor. The supervisor shall schedule re-training. The reason for the re-training shall be logged into the nonclinical administrative staff employee s personnel file by the employee s supervisor. 6.8 Completion of each re-training session shall be logged into the non-clinical administrative staff employee s personnel file by the employee s supervisor

156 Non-Clinical Administrative Staff Assessment CID Management Policy No Revision: 3.0 Revision Date: 1/27/2011 Page 1 of 7 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC President/Managing Director, CID 1.0 Purpose This policy establishes guidelines by which non-clinical administrative staff shall undergo assessment. 2.0 Revision History Revision /15/2006 New Policy and Forms/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /16/2009 Reviewed Revision /08/2010 Reviewed Revision /27/2011 Revised Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all non-clinical administrative staff employed by, or contracted with, CID Management. 4.0 Policy The policy of CID Management is to perform ongoing assessment of non-clinical administrative staff to identify strengths as well as areas in need of improvement. It is further the policy of CID Management to work with the non-clinical administrative staff member at the time of the assessment to create a personal development plan that the non-clinical administrative staff member shall endeavor to complete prior to the following scheduled assessment. 5.0 Definitions Definitions of terms are set forth in Policy Procedures

157 6.1 The Director of Production shall schedule periodic assessments for each non-clinical administrative staff member. The periodic assessments shall occur, at minimum, at the following times: At the 3 month anniversary with CID At the 6 month anniversary with CID At the 1 year anniversary with CID, and yearly thereafter. 6.2 Prior to the scheduled assessment, the Director of Production shall complete the attached assessment form. 6.3 Prior to the scheduled assessment, the Director of Production shall review a minimum of 5 reviews on which the non-clinical administrative staff member worked using the attached form to grade their performance. 6.4 During the scheduled assessment, the Director of Production shall review the assessment form with the non-clinical administrative staff member and explain all comments listed therein. The Director of Production shall answer any questions the non-clinical administrative staff member has in regard to the assessment form or comments. 6.5 Following the review of the assessment form, the Director of Production and the nonclinical administrative staff member shall complete the section on the final page entitled Action Plan. This shall constitute the non-clinical administrative staff member s personal development plan. 6.6 The non-clinical staff member shall then be provided the opportunity to add any comments to the form and then sign and date the form. 6.7 The Director of Production shall provide one copy of the final form to the nonclinical staff member and shall place a copy of the final form in the non-clinical staff member s personnel file. 6.8 The President/Managing Director shall schedule periodic assessments for each Director of Production. The periodic assessments shall occur, at minimum, at the following times: At the 3 month anniversary with CID At the 6 month anniversary with CID At the 1 year anniversary with CID, and yearly thereafter

158 6.9 Prior to the scheduled assessment, the President/Managing Director shall complete the attached assessment form Prior to the scheduled assessment, the Director of Production shall review a minimum of 5 reviews on which the non-clinical administrative staff member worked using the attached form to grade their performance During the scheduled assessment, the President/Managing Director shall review the assessment form with the Director of Production and explain all comments listed therein. The President/Managing Director shall answer any questions the Director of Production has in regard to the assessment form or comments Following the review of the assessment form, the President/Managing Director and the Director of Production shall complete the section on the final page entitled Action Plan. This shall constitute the Director of Production s personal development plan The Director of Production shall then be provided the opportunity to add any comments to the form and then sign and date the form The President/Managing Director shall provide one copy of the final form to the Director of Production and shall place a copy of the final form in the Director of Production s personnel file

159 CID Management Non-Clinical Administrative Staff Assessment Form Employee: Title: SSN: Review Period: to Supervisor s Name: Supervisor s Title: Type of Review: 90 Day 6 month performance Annual performance Instructions: 1. Rating: Rate the Employee in each job area, unless it is not applicable, by placing the rating in the box that best indicates where the Employee stands in relation to the accountability. Every factor must either be rated or marked NA/NO (not applicable/not observed). Indicate the overall rating at the end of the job area. 2. Remarks: Use the Remarks space after each job area to explain in more detail or to give examples of that area. All ratings except 3 require comments. 3. Summary: Complete the Major Accomplishments, Job-Related Strengths, Areas for Improvement/Development, Action Plan sections. Have the Employee complete the Employee Comments section. Use additional space if needed. 4. Signatures: Sign the review and have the Employee sign before filing the original form in the Employee s personnel file. Ratings and Meanings: 5 Performance consistently exceeds job requirements. Demonstrates unusually high level of performance relative to all assignments and objectives. Distinguished performance overall. 4 Performance meets and often exceeds job requirements. Demonstrates successful performance on all major assignments and objectives and consistently exceeds position requirements in some areas 3 Performance consistently meets job requirements. Demonstrates successful performance on all or most major assignments and objectives 2 Performance is inconsistent; meets some job requirements but not consistently. Overall performance is below the acceptable level and must improve to meet minimum position requirements. 1 Performance is consistently below job requirements. Fails to meet position requirements in most areas. A corrective action plan and performance improvements are mandatory. NA/NO Not applicable or has not been observed by the reviewer

160 Job Area Remarks Rating Professionalism Attitude: Maintains positive and pleasant demeanor. Consistently places the team above the individual. Acceptance of Responsibility: Takes on new tasks with enthusiasm. Accepts accountability for personal work. Professional/Personal Growth: Demonstrates improvement of skills and behaviors that strengthen both the individual and the company. Reliability: Can be relied upon to complete tasks and follow ups as needed. Work Professional Knowledge/Work Knowledge/Skills: Possesses and applies knowledge or skills necessary for task completion. Keeps current on new developments in areas of work. Quality of Work: Assignments are accurate, complete and comply with objectives. Quantity of Work: Produces significant volume of work to support goals within specified time frames. Communication: Maintains open, effective communications with all Employees and clients. Written and verbal communications are clear, concise, and understandable. Customer Service: Willingly serves customers providing assistance and information as needed. Helps find solutions to problems that are identified. Maintains professionalism at all times. Teamwork: Willingly cooperates, shares information, assists and is tolerant of others in daily interaction with all Employees, vendors, and clients. Adaptability/Flexibility: Easily adjusts to changes in routine, assignments, and company or client needs and continues to be productive. Initiative: Voluntarily recommends resourceful, alternative, or original ideas and procedures for work improvement or problem solution. Planning/Scheduling: Prioritizes tasks, anticipates needs, and makes adjustments. Problem Solving: Identifies problems within own area, develops resourceful solutions, and makes recommendations for corrective action

161 Summary Sections 1, 2, 3, and 4 are to be completed by the Supervisor(s). Section 5 is completed by Employee. 1. Major accomplishments since the last review: 2. Job related strengths: 3. Areas for improvement/development: 4. Action plan: 5. Employee s Comments: Signatures I acknowledge that this review has been discussed with me. My signature does not imply agreement or disagreement. Employee: Supervisor: Date: Date:

162 CID Management Non-Clinical Administrative Staff Review-Specific Assessment Score: Note: each checkbox that is checked off earns 5%. For a checkbox to be checked it has to be complete and of good quality. A blank checkbox means that area was missing or of poor quality. Client: CID Review #: Non-Clinical Administrative Staff: Date of Review: Claim & Patient Demographics (25%) Patient and Patient Demographics correct SSN, DOB, name, etc. Claim stakeholders correctly identified Stakeholder demographics correct Claim demographics correct claim #, DOI, injured body parts, etc. Correct organization and location. Review (35%) Review dates are correct Review stakeholders correctly identified Stakeholder demographics correct Review timeframe correctly identified Reason for review correctly identified Correct number of requested treatments/visits identified Correct date range for requested treatments/visits identified CID Stakeholders (20%) Correct administrative user identified Correct initial clinical reviewer identified Correct clinical peer reviewer identified Correct QAQC reviewer identified Activities and Documents (15%) All activities are documented Correct documents uploaded Follow up activities set, if applicable Migration Status is correct (5%) Overall impression: Notes:

163 Delegation of Non-Clinical Functions CID Management Policy No Revision: 1.0 Revision Date: 04/20/2008 Page 1 of 4 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines establishing requirements for delegation of functions performed by non-clinical administrative staff employed by CID to a non-cid vendor. 2.0 Revision History Revision /20/2008 New Policy & Form/Initial Implementation Revision /20/2009 Reviewed Revision /08/2010 Reviewed Revision /26/2011 Reviewed Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all non-clinical administrative staff members employed by vendors under contract with CID to perform utilization management operations. 4.0 Policy The policy of CID Management is to ensure that all non-clinical work performed on behalf of CID by a contracted vendor complies with all requirements and criteria applied to work performed by non-clinical administrative staff employed by CID. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 Upon identification of a potential vendor for providing functions performed by nonclinical administrative staff, the Clinical Director shall verify that the vendor holds current non-conditional accreditation by URAC for CORE standards

164 6.2 Prior to contractual agreement for delegation of non-clinical functions, the CID Committee on Policies and Procedures shall review the policies and procedures of the potential vendor. The Committee on Policies and Procedures shall report its findings to all CID Directors, and those findings must at minimum indicate that the vendor is in full compliance with CID polices and procedures, or must specifically identify any areas of potential non-compliance Potential vendors must have a policy that prohibits any system for reimbursement, bonuses, or incentives to staff based directly or indirectly on consumer utilization of health care services. 6.3 The Committee on Policies and Procedures shall obtain and review current policies and procedures of each vendor contractually performing delegated non-clinical functions at least annually, and shall perform a limited review in the event that the vendor advises CID of a material change in the manner or method of performing delegated functions. The Committee on Policies and Procedures shall report its findings to all CID Directors, and those findings must at minimum indicate that the vendor is in full compliance with CID polices and procedures, or must specifically identify any areas of potential non-compliance. 6.4 Delegated non-clinical functions must be governed by a written contractual agreement. All such written contracts must conform to the following criteria: All non-clinical functions which may be delegated to the vendor must be specified All non-clinical functions which may not be designated to the vendor must be specified. Non-clinical functions specifically excluded must be consistent with CID Policy 3100 (Pre-Review Screening). Any functions related to domains identified by the Committee on Policies and Procedures as non-compliant with CID policies and procedures must also be specified as excluded Contract must specify that vendor must perform all delegated functions in accordance with CID policies and procedures and URAC standards Vendor must be required to report any material change in the manner or method of performing delegated functions prior to enacting such change Contract must specify that CID may conduct surveys of the vendor as required Contract must require that the vendor submit periodic reports to CID regarding the performance of its delegated responsibilities Contract must require that in the event of identified problems or noncompliance with either CID policies/procedures or URAC standards, that the vendor will cease performing delegated functions related to the identified problem until correction has been successfully implemented Contract must specify that no non-clinical CID functions or work may be further delegated or subcontracted to another party or vendor

165 6.4.9 Contract must specify that all delegated non-clinical functions or work will be completed via the CID s proprietary medical management system and database Contract must specify that all persons directly involved in performing delegated non-clinical functions must be vetted by the CID Credentialing Committee prior to performing those functions, including provision of a non-disclosure agreement; a HIPAA agreement; and a conflict of interest form Contract must specify that all persons directly involved in performing delegated non-clinical functions must be provided with all job-specific training materials available to CID non-clinical staff. 6.5 The Director of Production shall perform periodic assessments for each vendor staff member performing delegated non-clinical functions. These periodic assessments shall occur, at minimum, at the following times: After 3 months of performing delegated non-clinical functions for CID After 6 months of performing delegated non-clinical functions for CID After 1 year of performing delegated non-clinical functions for CID, and yearly thereafter. 6.6 The assessment of vendor staff undertaken by the Director of Production shall consist of review of a minimum of 5 reviews on which the vendor staff member worked, using the attached form to grade their performance. 6.7 Periodic assessments of vendor staff are to be forwarded by the Director of Production to the CID Clinical Director. 6.8 The Clinical Director shall incorporate the outcomes of vendor staff assessment into annual reporting to the QAQC Committee

166 CID Management Non-Clinical Administrative Staff Review-Specific Assessment Score: Note: Items with one checkbox score 5%. Items on tables score 5% for being marked as Good (information on review was both correct and complete). Client: CID Review #: Non-Clinical Administrative Staff: Date of Review: Claim & Patient Demographics (25%) Good Inaccurate Missing Patient and Patient Demographics correct SSN, DOB, name, etc. Claim stakeholders correctly identified Stakeholder demographics correct Claim demographics correct claim #, DOI, injured body parts, etc. Correct organization and location. Review (35%) Good Inaccurate Missing Review dates are correct Review stakeholders correctly identified Stakeholder demographics correct Review timeframe correctly identified Reason for review correctly identified Correct number of requested treatments/visits identified Correct date range for requested treatments/visits identified CID Stakeholders (20%) Correct administrative user identified Correct initial clinical reviewer identified Correct clinical peer reviewer identified Correct QAQC reviewer identified Activities and Documents (15%) All activities are documented Correct documents uploaded Follow up activities set, if applicable Migration Status is correct (5%) Overall impression: Notes:

167 Initial Clinical Reviewer Credentialing CID Management Policy No Revision: 3.3 Revision Date: 3/10/11 Page 1 of 7 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which initial clinical reviewers contracted with CID to perform utilization management operations are credentialed. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /20/2008 Revised Revision /17/2009 Revised Revision /08/2010 Reviewed Revision /10/2011 Revised Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all initial clinical reviewers contracted with CID to perform utilization management operations. 4.0 Policy The policy of CID Management is to perform credentialing on all initial clinical reviewers upon initial contracting. It is further the policy of CID Management to perform recredentialing on all initial clinical reviewers on a yearly basis. 5.0 Definitions Definitions of terms are set forth in Policy Procedures

168 6.1 If, following the interview process, CID has determined that the candidate is a viable choice for the position and that a contract offer is desired, prior to making a contract offer the Recruiter of Clinical Personnel shall perform an initial credentialing check. 6.2 The initial credentialing check by the Recruiter of Clinical Personnel shall include primary source verification as appropriate including any, or all, of the following: State licensing boards -- validating the practitioner's license to practice and confirming whether there are any sanctions against the license Schools/training programs - validating the practitioner's highest level of training in his/her specialty and validating board certification status with the American Board of Medical Specialties National Technical Information Service (NTIS) -- validating the practitioner's license to prescribe drugs. The certificates reviewed are the Drug Enforcement Agency (DEA) certificate or Controlled Drug Substance Registration (CDS) Medicare/Medicaid - determining whether sanctions have been imposed by the federal government's Office of Inspector General (OIG) or Office of Personnel Management (OPM) Malpractice history - reviewing claims history. 6.3 The Recruiter of Clinical Personnel shall evaluate to determine if the candidate meets the following inclusion criteria: Has undergone formal training in a health care field Holds an associates degree in a health care field, or holds a state license, or state certificate in a health care field, Has professional experience in providing direct patient care, Holds a current unrestricted license to practice in a health care field Has an acceptable malpractice history. 6.4 The Recruiter of Clinical Personnel shall also evaluate to determine if the candidate meets the following exclusion criteria: Has a history of revocation, suspension or limitation to practice their health care discipline, Has a sanction or disciplinary action within the past five years by their licensing board,

169 6.4.3 Has an unacceptable malpractice history, Has a history of felony convictions. 6.5 If, upon initial credentialing, the Recruiter of Clinical Personnel discovers that the candidate meets all inclusion criteria as outlined in CID Policy 2100, and does not meet any exclusion criteria as outlined in CID Policy 2100, the Recruiter of Clinical Personnel shall forward documentation from primary verification sources to the Director of Clinical Personnel. The Director of Clinical personnel shall also verify that the candidate meets all inclusion criteria from CID Policy 2100 and none of the exclusion from CID Policy 2100 The Director of Clinical Personnel shall conclude that the candidate has passed the credentialing process and shall disclose this information to the Recruiter of Clinical Personnel and Clinical Director. 6.6 If, upon initial credentialing, the Recruiter of Clinical Personnel or the Director of Clinical Personnel discovers any item that precludes the candidate from meeting all inclusion criteria as outlined in CID Policy 2100, or any item that matches any exclusion criteria as outlined in CID Policy 2100, the Recruiter of Clinical Personnel or the Director of Clinical Personnel shall conclude that the candidate has not passed the credentialing process and shall disclose this information to the Recruiter of Clinical Personnel; the Director of Clinical Personnel; and Clinical Director. The party providing such disclosure shall further indicate the principle reason(s) the candidate did not pass the credentialing process. 6.7 If the candidate successfully passed the credentialing process, the Recruiter of Clinical Personnel; the Director of Clinical Personnel; or the Clinical Director shall contact the candidate with a contract offer. 6.8 If the candidate has not passed the credentialing process, the Director of Clinical Personnel or Clinical Director shall contact the candidate to inform him/her that no contract offer will be made and provide the candidate of the principle reason(s) he/she did not pass the credentialing process. 6.9 The candidate shall have the opportunity to respond to the principle reason(s); however in absence of proving the unsuccessful attempt at credentialing was due to incorrect information, the credentialing decision shall stand The Director of Clinical Personnel shall insure that a re-credentialing of all initial clinical reviewers is performed by the Director of Clinical Personnel or a Recruiter of Clinical Personnel at regular intervals, not to exceed 1 year and no later than scheduled expiration of licensure/certification. The performance of this credentialing shall include primary source verification as appropriate including any, or all, of the following:

170 State licensing boards -- validating the practitioner's license to practice and confirming whether there are any sanctions against the license Validating board certification status with the American Board of Medical Specialities National Technical Information Service (NTIS) -- validating the practitioner's license to prescribe drugs. The certificates reviewed are the Drug Enforcement Agency (DEA) certificate or Controlled Drug Substance Registration (CDS) Medicare/Medicaid - determining whether sanctions have been imposed by the federal government's Office of Inspector General (OIG) or Office of Personnel Management (OPM) Malpractice history - reviewing claims history The periodic re-credentialing evaluation shall determine if the initial clinical reviewer continues to meet all of the inclusion criteria from CID Policy 2100; and shall determine that the initial clinical reviewer meets none of the exclusion criteria from CID Policy If, upon re-credentialing, the Director of Clinical Personnel or a Recruiter of Clinical Personnel discovers that the initial clinical reviewer meets all inclusion criteria as outlined in CID Policy 2100, and does not meet any exclusion criteria as outlined in CID Policy 2100, the Director of Clinical Personnel or a Recruiter of Clinical Personnel shall conclude that the initial clinical reviewer has passed the credentialing process and shall document this in the initial clinical reviewer s personnel file If, upon re-credentialing, the Director of Clinical Personnel or a Recruiter of Clinical Personnel discovers any item that precludes the initial clinical reviewer from meeting all inclusion criteria as outlined in CID Policy 2100, or any item that matches any exclusion criteria as outlined in CID Policy 2100, the Director of Clinical Personnel or a Recruiter of Clinical Personnel shall conclude that the initial clinical reviewer has not passed the credentialing process and shall disclose this information to the Director of Clinical Personnel and the Clinical Director. Such disclosure shall further include the principle reason(s) the initial clinical reviewer did not pass the recredentialing process If the initial clinical reviewer has not passed the re-credentialing process, the Medical Director or Clinical Director shall contact the initial clinical reviewer to inform him/her that his/her contract will be terminated and provide the initial clinical reviewer of the principle reason(s) he/she did not pass the credentialing process

171 6.15 The initial clinical reviewer shall have the opportunity to respond to the principle reasons, however in absence of proving the unsuccessful attempt at re-credentialing was due to incorrect information, the credentialing decision and contract termination shall stand

172 Addendum State of Tennessee 1.0 Any doctor serving as an initial clinical reviewer in association with claims in the Tennessee jurisdiction must have a valid, active license to practice in Tennessee. 2.0 All other personnel serving as initial clinical reviewers in association with claims in the Tennessee jurisdiction must have a valid, active license as a Registered Nurse in any jurisdiction within the United States

173 Addendum State of Texas 3.0 Any doctor serving as an initial clinical reviewer in association with claims in the Texas jurisdiction must have a valid, active license to practice in Texas. 4.0 All other personnel serving as initial clinical reviewers in association with claims in the Texas jurisdiction shall be nurses, physicians assistants, or health care providers qualified to provide the service requested by the provider

174 Initial Clinical Reviewer Initial Paperwork CID Management Policy No Revision: 3.1 Revision Date: 3/16/2011 Page 1 of 4 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines for paperwork required to be signed by initial clinical reviewer prior to being contracted with CID to perform utilization management operations. 2.0 Revision History Revision /15/2006 New Policy and Forms/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /16/2009 Reviewed Revision /08/2010 Reviewed Revision /16/2011 Revised Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all initial clinical reviewer members contracted by CID to perform utilization management operations. 4.0 Policy The policy of CID Management is to require the following items to be completed by all initial clinical reviewer members contracted by CID to perform utilization management operations prior to commencement of the contractor relationship: 4.1 Initial clinical reviewer contract 4.2 Non-disclosure agreement 4.3 CID/business associate HIPAA agreement 4.4 Conflict of interest form 4.5 W2 or W9, as applicable

175 It is further the policy of CID Management to require the following items be submitted by all initial clinical reviewers contracted by CID to perform utilization management operations prior to commencement of the contractor relationship: 4.6 Copy of current health care provider licenses 4.7 Listing of all active and inactive health care provider licenses ever held 4.8 Disclosure of all prior disciplinary actions taken by health care licensing boards as well as any prior malpractice actions. 4.9 Completed Electronic Signature Form. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 Upon official offer of an contractor position, CID shall request the candidate provide the following documents: Copy of current curriculum vitae, if available Copy of current health care provider licenses Listing of all active and inactive health care provider licenses ever held Disclosure of all prior disciplinary actions taken by health care licensing boards as well as any prior malpractice actions Completed Electronic Signature Form. 6.2 Upon official offer of an contractor position, CID shall provide the candidate with a copy of, and shall review, explain and answer any questions from the candidate regarding the following documents: Initial clinical reviewer contract Non-disclosure agreement CID/business associate HIPAA agreement Conflict of interest form

176 6.2.5 W2 or W9, as appropriate 6.3 The candidate shall have all the time they feel they require to review the documents and ask questions of CID. 6.4 Upon receipt of all documents listed in 6.1 and receipt of all completed documents listed in section 6.2, the contractor shall begin employment at CID

177 CID Management Electronic Signature Form Your name and electronic signature will be added to all documents that you create within the CID system (e.g. determination letters, requests for additional information). To capture and create your electronic signature, you need to: 1) Sign in each of the boxes below 2) Use black or blue ink 3) Make sure that your signature does not touch or cross any of the box boundaries Once you have signed each of the boxes, please fax this form to Following that, please mail a hardcopy of this page to CID at 2415 San Ramon Valley Blvd #4414, San Ramon, CA Thank you. I hereby authorize CID to create an electronic signature for me, using the signatures in the boxes above, and to attach this signature to any documents generated by me within the CID system. Signature: Date:

178 Initial Clinical Reviewer Training CID Management Policy No Revision: 5.0 Revision Date: 1/29/2008 Page 1 of 3 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines for training provided to initial clinical reviewers contracted with CID to perform utilization management operations. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /24/2006 Addition of training in URAC standards Revision /26/2006 Revised Revision /05/2007 Revised Revision /29/2008 Revised Revision /16/2009 Reviewed Revision /08/2010 Reviewed Revision /11/2011 Reviewed Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all initial clinical reviewers contracted with CID to perform utilization management operations. 4.0 Policy The policy of CID Management is to provide initial clinical reviewers, contracted with CID to perform utilization management operations, with the following training sessions: 4.1 Introduction to CID 4.2 Introduction to workers compensation 4.3 Introduction to utilization management Overview of utilization management

179 4.3.2 Labor code, regulations, and case law regarding utilization management CID s utilization management process URAC utilization management standards 4.4 Conflict of interest policies and procedures 4.5 Confidentiality policies and procedures 4.6 Job specific training 4.7 Periodic Training Updates as required including: Changes to the CID utilization management process Changes to labor code, regulations, or case law regarding utilization management 4.8 Training on identification and prevention of fraud and abuse, as appropriate to job functions 4.9 Re-Training on an annual basis. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 Upon hire, the Clinical Director or Senior Clinical Staff shall schedule the following training sessions for the new initial clinical reviewer contractor: Introduction to CID Introduction to workers compensation Introduction to utilization management Overview of utilization management Labor code, regulations, and case law regarding utilization management CID s utilization management process

180 URAC utilization management standards Conflict of interest policies and procedures Confidentiality policies and procedures Job specific training Identification of fraud and abuse 6.2 Completion of each training session in section 6.1 shall be logged into the initial clinical reviewer s personnel file by the Clinical Director or Senior Clinical Staff. 6.3 As needed, the Clinical Director or Senior Clinical Staff shall schedule periodic training updates for all initial clinical reviewers. 6.4 Completion of periodic training updates may be logged into the initial clinical reviewer s personnel file at the discretion of the Clinical Director or Senior Clinical Staff. 6.5 If the Clinical Director or Senior Clinical Staff notes an area of performance in which the initial clinical reviewer is not adhering to CID s policies and procedures, or in which the job duties are being performed in an unacceptable fashion, the Clinical Director or Senior Clinical Staff shall schedule re-training. The reason for the retraining shall be logged into the initial clinical reviewer s personnel file by the Clinical Director or Senior Clinical Staff. 6.6 Completion of each re-training session shall be logged into the initial clinical reviewer s personnel file by the Clinical Director or Senior Clinical Staff. 6.7 If QAQC committee notes an area of performance in which the initial clinical reviewer is not adhering to CID s policies and procedures, or in which the job duties are being performed in an unacceptable fashion, they shall communicate this to the initial clinical reviewer and the Clinical Director or Senior Clinical Staff. The Clinical Director or Senior Clinical Staff shall schedule re-training. The reason for the retraining shall be logged into the initial clinical reviewer s personnel file by the Clinical Director or Senior Clinical Staff. 6.8 Completion of each re-training session shall be logged into the initial clinical reviewer s personnel file by the Clinical Director or Senior Clinical Staff

181 Initial Clinical Reviewer Assessment CID Management Policy No Revision: 4.1 Revision Date: 3/11/2011 Page 1 of 3 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which initial clinical reviewer shall undergo assessment. 2.0 Revision History Revision /15/2006 New Policy and Forms/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /14/2009 Revised Revision /08/2010 Reviewed Revision /27/2011 Reviewed Revision /11/2011 Revised Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all initial clinical reviewers employed by, or contracted with, CID Management. 4.0 Policy The policy of CID Management is to perform ongoing assessment of initial clinical reviewers to identify strengths as well as areas in need of improvement. It is further the policy of CID Management to work with the initial clinical reviewers at the time of the assessment to create a personal development plan that the initial clinical reviewers shall endeavor to complete prior to the following scheduled assessment. 5.0 Definitions Definitions of terms are set forth in Policy Procedures

182 6.1 The Clinical Director or Senior Clinical Staff shall conduct periodic assessments for each initial clinical reviewer. The periodic assessments shall occur with reference to the following intervals: At the 3 month anniversary with CID At the 6 month anniversary with CID At the 1 year anniversary with CID, and yearly thereafter. 6.2 The scheduled assessment will include consideration of reviews on which the initial reviewer worked, using the attached form to grade their performance. The performance assessment forms will be completed by the Clinical Director or Senior Clinical Staff. Whenever possible, a minimum of 5 reviews on which the initial clinical reviewer worked should be considered during each assessment interval. 6.3 As review assessments are completed, the Clinical Director or Senior Clinical Staff member who completed the assessment shall provide the assessment form and the draft assessed to the initial clinical reviewer, with explanations of all noted issues. The Clinical Director or Senior Clinical Staff member who completed the assessment shall invite the initial reviewer to discuss any questions or concerns regarding the assessment; and shall be available for such discussion. 6.4 In the event that an initial reviewer is noted to have similar performance issues on a consistent or repetitive basis, the Clinical Director or Director of Clinical Training and Assessment shall make available appropriate re-training resources. 6.5 The Clinical Director or Director of Clinical Training and Assessment shall place a copy of each assessment form in the initial clinical reviewer s personnel file

183 Initial clinical reviewer: CID Review #: State/Jurisdiction: CID Management Initial clinical reviewer Assessment Form Date of Assessment: Assessment Performed by: (4 = excellent/yes;3 = very good;2 = good; 1 = poor;0 = very poor/no) Document Summaries Reviewer summarized all appropriate documents received 4 0 N/A Document summaries were concise N/A Document summaries contained all relevant clinical information N/A Requests for Information, if applicable Request clearly outlines the info required from the provider N/A Request is for info reasonably necessary to make the determination N/A Request is for info not previously available through the CID system N/A Clinical Rationale Reviewer appears to have considered determinations in past reviews N/A Reviewer appears to have considered all documents received on claim 4 0 Rationale contains basic claim demographics 4 0 Rationale clearly states the requested service and/or procedure 4 0 Rationale clearly states the determination 4 0 Rationale contains relevant history of care to date, if provided 4 0 N/A Rationale contains relevant patient subjective and objective findings Rationale is not based on non-industrial causation or billing factors Rationale provides a clear and concise systematic argument outlining logic used to make determination of medical necessity Reviewer s determination demonstrates appropriate use of evidence based medicine approach clinical expertise, patient response to care & scientific/guidelines evidence Guidelines Reviewer referenced state mandated guidelines first 4 0 Guidelines selection was concise 4 0 Appropriate guidelines were cited to support the clinical rationale position Guidelines selection was specific to the diagnosis and requested treatment Migrating Review Reviewer had appropriate rationale for migrating the review to the next appropriate person (e.g. clinical peer reviewer; QAQC reviewer) 4 0 Timelines Reviewed completed review in appropriate time frame 4 0 Spelling/Organization Spelling, grammar, construction of paragraphs appropriate Total (if AMI involved): / 92 Total (no AMI involved): / 80 Overall impression & Notes:

184 Delegation of Initial Clinical Review Functions CID Management Policy No Revision: 1.0 Revision Date: 5/14/2009 Page 1 of 5 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines establishing requirements for delegation of functions performed by initial clinical reviewers to a non-cid vendor. 2.0 Revision History Revision /20/2008 New Policy & Form/Initial Implementation Revision /14/2009 Revised Revision /08/2010 Reviewed Revision /26/2011 Reviewed Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all clinical staff employed by vendors under contract with CID to perform functions that are components of an initial clinical review. 4.0 Policy The policy of CID Management is to ensure that all initial clinical review functions performed on behalf of CID by a contracted vendor complies with all requirements and criteria applied to work performed by initial clinical reviewers employed by CID. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 Upon identification of a potential vendor for providing functions performed by initial clinical reviewers, the Clinical Director shall verify that the vendor holds current nonconditional accreditation by URAC for CORE standards. 6.2 Prior to contractual agreement for delegation of initial clinical review functions, the CID Committee on Policies and Procedures shall review the policies and procedures

185 of the potential vendor. The Committee on Policies and Procedures shall report its findings to all CID Directors, and those findings must at minimum indicate that the vendor is in full compliance with CID polices and procedures, or must specifically identify any areas of potential non-compliance Potential vendors must have a policy that prohibits any system for reimbursement, bonuses, or incentives to staff based directly or indirectly on consumer utilization of health care services. 6.3 The Committee on Policies and Procedures shall obtain and review current policies and procedures of each vendor contractually performing delegated initial clinical review functions at least annually, and shall perform a limited review in the event that the vendor advises CID of a material change in the manner or method of performing delegated functions. The Committee on Policies and Procedures shall report its findings to all CID Directors, and those findings must at minimum indicate that the vendor is in full compliance with CID polices and procedures, or must specifically identify any areas of potential non-compliance. 6.4 Delegated initial clinical review functions must be governed by a written contractual agreement. All such written contracts must conform to the following criteria: All initial clinical review functions which may be delegated to the vendor must be specified, and must be consistent with CID Policy 3200 (Initial Clinical Review) All clinical functions which may not be designated to the vendor must be specified. Clinical functions specifically excluded must be consistent with CID Policy 3200 (Initial Clinical Review). Any functions related to domains identified by the Committee on Policies and Procedures as noncompliant with CID policies and procedures must also be excluded Contract must specify that vendor must perform all delegated functions in accordance with CID policies and procedures and URAC standards Vendor must be required to report any material change in the manner or method of performing delegated functions prior to enacting such change Contract must specify that CID may conduct surveys of the vendor as required Contract must require that the vendor submit periodic reports to CID regarding the performance of its delegated responsibilities Contract must require that in the event of identified problems or noncompliance with either CID policies/procedures or URAC standards, that the vendor will cease performing delegated functions related to the identified problem until correction has been successfully implemented Contract must specify that no initial clinical review CID functions or work may be further delegated or subcontracted to another party or vendor Contract must specify that all delegated initial clinical review functions or work will be completed via the CID s proprietary medical management system and database

186 Contract must specify that each person directly involved in performing delegated initial clinical review functions must be vetted by the CID Credentialing Committee prior to performing those functions, including provision of a copy of a valid clinical license; documentation of malpractice insurance coverage; a copy of a curriculum vitae, including education and history of providing direct patient care; non-disclosure agreement; a HIPAA agreement; and a conflict of interest form Contract must specify that the vendor will provide certification for each person involved in performing delegated initial clinical review functions has no history of revocation, suspension or limitation to practice their health care discipline; no sanction or disciplinary action within the past five years by their licensing board; no history of malpractice claims or convictions; and no history of felony convictions Contract must specify that any person deemed by the CID Credentialing Committee to be unqualified or unsuitable as an initial clinical reviewer shall be prohibited from performing any delegated functions of initial clinical review on behalf of CID Contract must specify that documentation described in and shall be provided to the CID Credentialing Committee at least annually for re-credentialing of each person performing delegated initial clinical review functions Contract must specify that all persons directly involved in performing delegated initial clinical review functions must be provided with all jobspecific training materials available to CID initial clinical reviewers Individuals who conduct initial clinical review have access to consultation with a licensed doctor of medicine or doctor of osteopathic medicine; or licensed health professional in the same licensure category as the ordering provider; or a health professional with the same clinical education as the ordering provider in clinical specialties where licensure is not issued. The contract must specify whether the vendor or CID is to provide this professional support. In the event that the vendor provides this support, person(s) providing the support must be vetted by the CID Credentialing Committee prior to the commencement of delegated initial review functions. 6.5 The Clinical Director shall perform periodic assessments for each vendor staff member performing delegated initial clinical review functions. These periodic assessments shall occur, at minimum, at the following times: After 3 months of performing delegated initial clinical review functions for CID After 6 months of performing delegated initial clinical review functions for CID

187 6.5.3 After 1 year of performing delegated initial clinical review functions for CID, and yearly thereafter. 6.6 The assessment of vendor staff undertaken by the Clinical Director shall consist of review of a minimum of 5 reviews on which the vendor staff member worked, using the attached form to grade their performance. 6.7 The Clinical Director shall incorporate the outcomes of vendor staff assessment into annual reporting to the QAQC Committee. 6.8 No initial clinical review functions shall be delegated for emergency, urgent, expedited or concurrent reviews. 6.9 All reviews for which initial clinical reviewer functions have been delegated to a non- CID contracted vendor shall be verified for correctness and accuracy by a CID QA/QC reviewer prior to release of any determination letters

188 Initial clinical reviewer: CID Review #: State/Jurisdiction: Date of Assessment: Assessment Performed by: (4 = excellent/yes;3 = very good;2 = good; 1 = poor;0 = very poor/no) Document Summaries Reviewer summarized all appropriate documents received 4 0 N/A Document summaries were concise N/A Document summaries contained all relevant clinical information N/A Requests for Information, if applicable Request clearly outlines the info required from the provider N/A Request is for info reasonably necessary to make the determination N/A Request is for info not previously available through the CID system N/A Clinical Rationale Reviewer appears to have considered determinations in past reviews N/A Reviewer appears to have considered all documents received on claim 4 0 Rationale contains basic claim demographics 4 0 Rationale clearly states the requested service and/or procedure 4 0 Rationale clearly states the determination 4 0 Rationale contains relevant history of care to date, if provided 4 0 N/A Rationale contains relevant patient subjective and objective findings Rationale is not based on non-industrial causation or billing factors Rationale provides a clear and concise systematic argument outlining logic used to make determination of medical necessity Reviewer s determination demonstrates appropriate use of evidence based medicine approach clinical expertise, patient response to care & scientific/guidelines evidence Guidelines Reviewer referenced state mandated guidelines first 4 0 Guidelines selection was concise 4 0 Appropriate guidelines were cited to support the clinical rationale position Guidelines selection was specific to the diagnosis and requested treatment Migrating Review Reviewer had appropriate rationale for migrating the review to the next appropriate person (e.g. clinical peer reviewer; QAQC reviewer) 4 0 Timelines Reviewed completed review in appropriate time frame 4 0 Spelling/Organization Spelling, grammar, construction of paragraphs appropriate Total (if AMI involved): / 92 Total (no AMI involved): / 80 Overall impression & Notes:

189 Clinical Peer Reviewer Credentialing CID Management Policy No Revision: 3.3 Revision Date: 3/11/2011 Page 1 of 9 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which clinical peer reviewers contracted with CID to perform utilization management operations are credentialed. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /20/2008 Revised Revision /21/2009 Revised Revision /08/2010 Reviewed Revision /27/2011 Reviewed Revision /11/2011 Revised Revision /22/2011 Reviewed Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all clinical peer reviewers contracted with CID to perform utilization management operations. 4.0 Policy The policy of CID Management is to perform credentialing on all clinical peer reviewers upon initial contracting. It is further the policy of CID Management to perform recredentialing on all clinical peer reviewers on a yearly basis. 5.0 Definitions Definitions of terms are set forth in Policy Procedures

190 6.1 If, following the interview process, CID has determined that the candidate is a viable choice for the position and that a contract offer is desired, prior to making a contract offer the Recruiter of Clinical Personnel shall perform an initial credentialing check. 6.2 The initial credentialing check by the Recruiter of Clinical Personnel shall include primary source verification as appropriate including any, or all, of the following: State licensing boards -- validating the practitioner's license to practice and confirming whether there are any sanctions against the license Schools/training programs - validating the practitioner's highest level of training in his/her specialty and validating board certification status with the American Board of Medical Specialities National Technical Information Service (NTIS) -- validating the practitioner's license to prescribe drugs. The certificates reviewed are the Drug Enforcement Agency (DEA) certificate or Controlled Drug Substance Registration (CDS) Medicare/Medicaid - determining whether sanctions have been imposed by the federal government's Office of Inspector General (OIG) or Office of Personnel Management (OPM) Malpractice history - reviewing claims history. 6.3 The Recruiter of Clinical Personnel shall evaluate to determine if the candidate meets the following inclusion criteria: Has undergone formal training in a health care field Holds an associates degree in a health care field, or holds a state license, or state certificate in a health care field, Has professional experience in proving direct patient care, Holds a current unrestricted license to practice in a health care field Has an acceptable malpractice history. 6.4 The Recruiter of Clinical Personnel shall also evaluate to determine if the candidate meets the following exclusion criteria: Has a history of revocation, suspension or limitation to practice their health care discipline, Has a sanction or disciplinary action within the past five years by their licensing board,

191 6.4.3 Has an unacceptable malpractice history, Has a history of felony convictions. 6.5 If, upon initial credentialing, the Recruiter of Clinical Personnel discovers that the candidate meets all inclusion criteria as outlined in CID Policy 2200, and does not meet any exclusion criteria as outlined in CID Policy 2200, the Recruiter of Clinical Personnel shall forward documentation from primary verification sources to the Director of Clinical Personnel. The Director of Clinical personnel shall also verify that the candidate meets all inclusion criteria from CID Policy 2200 and none of the exclusion from CID Policy 2200 The Director of Clinical Personnel shall conclude that the candidate has passed the credentialing process and shall disclose this information to the Recruiter of Clinical Personnel and Clinical Director. 6.6 If, upon initial credentialing, the Recruiter of Clinical Personnel or the Director of Clinical Personnel discovers any item that precludes the candidate from meeting all inclusion criteria as outlined in CID Policy 2200, or any item that matches any exclusion criteria as outlined in CID Policy 2200, the Recruiter of Clinical Personnel or the Director of Clinical Personnel shall conclude that the candidate has not passed the credentialing process and shall disclose this information to the Recruiter of Clinical Personnel; the Director of Clinical Personnel; and Clinical Director. The party providing such disclosure shall further indicate the principle reason(s) the candidate did not pass the credentialing process. 6.7 If the candidate successfully passed the credentialing process, the Recruiter of Clinical Personnel; the Director of Clinical Personnel; or the Clinical Director shall contact the candidate with a contract offer. 6.8 If the candidate has not passed the credentialing process, the Director of Clinical Personnel or Clinical Director shall contact the candidate to inform him/her that no contract offer will be made and provide the candidate of the principle reason(s) he/she did not pass the credentialing process. 6.9 The candidate shall have the opportunity to respond to the principle reason(s); however in absence of proving the unsuccessful attempt at credentialing was due to incorrect information, the credentialing decision shall stand The Director of Clinical Personnel shall insure that a re-credentialing of all initial clinical reviewers is performed by the Director of Clinical Personnel or a Recruiter of Clinical Personnel at regular intervals,, not to exceed 1 year and no later than scheduled expiration of licensure/certification.. The performance of this credentialing shall include primary source verification as appropriate including any, or all, of the following:

192 State licensing boards -- validating the practitioner's license to practice and confirming whether there are any sanctions against the license Validating board certification status with the American Board of Medical Specialities National Technical Information Service (NTIS) -- validating the practitioner's license to prescribe drugs. The certificates reviewed are the Drug Enforcement Agency (DEA) certificate or Controlled Drug Substance Registration (CDS) Medicare/Medicaid - determining whether sanctions have been imposed by the federal government's Office of Inspector General (OIG) or Office of Personnel Management (OPM) Malpractice history - reviewing claims history The periodic re-credentialing evaluation shall determine if the initial clinical reviewer continues to meet all of the inclusion criteria from CID Policy 2200; and shall determine that the initial clinical reviewer meets none of the exclusion criteria from CID Policy 2200: 6.12 If, upon re-credentialing, the Director of Clinical Personnel or a Recruiter of Clinical Personnel discovers that the clinical peer reviewer meets all inclusion criteria as outlined in CID Policy 2200, and does not meet any exclusion criteria as outlined in CID Policy 2200, the Director of Clinical Personnel or a Recruiter of Clinical Personnel shall conclude that the clinical peer reviewer has passed the credentialing process and shall document this in the clinical peer reviewer s personnel file If, upon re-credentialing, the Director of Clinical Personnel or a Recruiter of Clinical Personnel discovers any item that precludes the clinical peer reviewer from meeting all inclusion criteria as outlined in CID Policy 2200, or any item that matches any exclusion criteria as outlined in CID Policy 2200, the Director of Clinical Personnel or a Recruiter of Clinical Personnel shall conclude that the clinical peer reviewer has not passed the credentialing process and shall disclose this information to the Director of Clinical Personnel and the Clinical Director. Such disclosure shall further include the principle reason(s) the clinical peer reviewer did not pass the recredentialing process If the clinical peer reviewer has not passed the re-credentialing process, the Medical Director or Clinical Director shall contact the clinical peer reviewer to inform him/her that his/her contract will be terminated and provide the clinical peer reviewer of the principle reason(s) he/she did not pass the credentialing process The clinical peer reviewer shall have the opportunity to respond to the principle reasons, however in absence of proving the unsuccessful attempt at re-credentialing

193 was due to incorrect information, the credentialing decision and contract termination shall stand

194 Addendum State of California 1.0 The clinical peer reviewer may be a: medical doctor; doctor of osteopathy; psychologist; acupuncturist; optometrist; dentist; podiatrist; or chiropractic practitioner. 2.0 The clinical peer reviewer must be licensed, by any state or the District of Columbia. 3.0 The clinical peer reviewer must be competent to evaluate the specific clinical issues involved in medical treatment services, where these services are within the scope of the reviewer's practice

195 Addendum Commonwealth of Massachusetts 1.0 The credentialing process shall further verify that clinical peer reviewers practice a minimum of 8 hours per week if they will be performing utilization management functions on claims originating in the Commonwealth of Massachusetts

196 Addendum State of Tennessee 1.0 The credentialing process shall further verify that clinical peer reviewers are physicians who are licensed and domiciled in Tennessee

197 Addendum State of Texas 1.0 The credentialing process shall further verify that clinical peer reviewers who are doctors are licensed to practice in Texas

198 Clinical Peer Reviewer Initial Paperwork CID Management Policy No Revision: 3.0 Revision Date: 3/16/2011 Page 1 of 4 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines for paperwork required to be signed by clinical peer reviewer prior to being contracted with CID to perform utilization management operations. 2.0 Revision History Revision /15/2006 New Policy and Forms/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /16/2011 Revised Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all clinical peer reviewer members contracted by CID to perform utilization management operations. 4.0 Policy The policy of CID Management is to require the following items to be completed by all clinical peer reviewer members contracted by CID to perform utilization management operations prior to commencement of the contractor relationship: 4.1 Clinical peer reviewer contract 4.2 Non-disclosure agreement 4.3 CID/business associate HIPAA agreement 4.4 Conflict of Interest form 4.5 W2 or W9, as applicable

199 It is further the policy of CID Management to require the following items be submitted by all clinical peer reviewers contracted by CID to perform utilization management operations prior to commencement of the contractor relationship: 4.6 Copy of current curriculum vitae 4.7 Copy of current health care provider licenses 4.8 Listing of all active and inactive health care provider licenses ever held 4.9 Copy of current malpractice insurance policy coversheet 4.10 Disclosure of all prior disciplinary actions taken by health care licensing boards as well as any prior malpractice actions Completed Electronic Signature Form. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 Upon official offer of an contractor position, CID shall request the candidate provide the following documents: Copy of current curriculum vitae Copy of current health care provider licenses Listing of all active and inactive health care provider licenses ever held Copy of current malpractice insurance policy coversheet Disclosure of all prior disciplinary actions taken by health care licensing boards as well as any prior malpractice actions Completed Electronic Signature Form. 6.2 Upon official offer of an contractor position, CID shall provide the candidate with a copy of, and shall review, explain and answer any questions from the candidate regarding the following documents: Clinical peer reviewer contract

200 6.2.2 Non-disclosure agreement CID/business associate HIPAA agreement Conflict of interest form W2 or W9, as applicable 6.3 The candidate shall have all the time they feel they require to review the documents and ask questions of CID. 6.4 Upon receipt of all documents listed in 6.1 and receipt of all completed documents listed in section 6.2, the contractor shall begin employment at CID

201 CID Management Electronic Signature Form Your name and electronic signature will be added to all documents that you create within the CID system (e.g. determination letters, requests for additional information). To capture and create your electronic signature, you need to: 1) Sign in each of the boxes below 2) Use black or blue ink 3) Make sure that your signature does not touch or cross any of the box boundaries Once you have signed each of the boxes, please fax this form to Following that, please mail a hardcopy of this page to CID at 2415 San Ramon Valley Blvd #4414, San Ramon, CA Thank you. I hereby authorize CID to create an electronic signature for me, using the signatures in the boxes above, and to attach this signature to any documents generated by me within the CID system. Signature: Date:

202 Clinical Peer Reviewer Training CID Management Policy No Revision: 4.0 Revision Date: 1/29/2008 Page 1 of 3 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines for training provided to clinical peer reviewers contracted with CID to perform utilization management operations. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /24/2006 Addition of training in URAC standards Revision /26/2006 Revised Revision /05/2007 Revised Revision /29/2008 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /11/2011 Reviewed Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all clinical peer reviewers contracted with CID to perform utilization management operations. 4.0 Policy The policy of CID Management is to provide clinical peer reviewers, contracted with CID to perform utilization management operations, with the following training sessions: 4.1 Introduction to CID 4.2 Introduction to workers compensation 4.3 Introduction to utilization management Overview of utilization management

203 4.3.2 Labor code, regulations, and case law regarding utilization management CID s utilization management process URAC utilization management standards 4.4 Conflict of interest policies and procedures 4.5 Confidentiality policies and procedures 4.6 Job specific training 4.7 Periodic Training Updates as required including: Changes to the CID utilization management process Changes to labor code, regulations, or case law regarding utilization management 4.8 Training on identification and prevention of fraud and abuse, as appropriate to job functions 4.9 Re-Training on an annual basis. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 Upon hire, the Clinical Director or Senior Clinical Staff shall schedule the following training sessions for the new clinical peer reviewer contractor: Introduction to CID Introduction to workers compensation Introduction to utilization management Overview of utilization management Labor code, regulations, and case law regarding utilization management CID s utilization management process

204 URAC utilization management standards Conflict of interest policies and procedures Confidentiality policies and procedures Job specific training Identification of fraud and abuse 6.2 Completion of each training session in section 6.1 shall be logged into the clinical peer reviewer s personnel file by the Clinical Director or Senior Clinical Staff. 6.3 As needed, the Clinical Director or Senior Clinical Staff shall schedule periodic training updates for all clinical peer reviewers. 6.4 Completion of periodic training updates may be logged into the clinical peer reviewer s personnel file at the discretion of the Clinical Director or Senior Clinical Staff. 6.5 If the Clinical Director or Senior Clinical Staff notes an area of performance in which the clinical peer reviewer is not adhering to CID s policies and procedures, or in which the job duties are being performed in an unacceptable fashion, the Clinical Director or Senior Clinical Staff shall schedule re-training. The reason for the retraining shall be logged into the clinical peer reviewer s personnel file by the Clinical Director or Senior Clinical Staff. 6.6 Completion of each re-training session shall be logged into the clinical peer reviewer s personnel file by the Clinical Director or Senior Clinical Staff. 6.7 If QAQC committee notes an area of performance in which the clinical peer reviewer is not adhering to CID s policies and procedures, or in which the job duties are being performed in an unacceptable fashion, they shall communicate this to the clinical peer reviewer and the Clinical Director or Senior Clinical Staff. The Clinical Director or Senior Clinical Staff shall schedule re-training. The reason for the re-training shall be logged into the clinical peer reviewer s personnel file by the Clinical Director or Senior Clinical Staff. 6.8 Completion of each re-training session shall be logged into the clinical peer reviewer s personnel file by the Clinical Director or Senior Clinical Staff

205 Clinical Peer Reviewer Assessment CID Management Policy No Revision: 4.1 Revision Date: 3/11/2011 Page 1 of 3 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which clinical peer reviewers, Medical Director, and Clinical Director shall undergo assessment. 2.0 Revision History Revision /15/2006 New Policy and Forms/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /14/2009 Revised Revision /08/2010 Reviewed Revision /27/2011 Reviewed Revision /11/2011 Revised Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all clinical peer reviewers, Medical Director, and Clinical Director employed by, or contracted with, CID Management. 4.0 Policy The policy of CID Management is to perform ongoing assessment of clinical peer reviewers including the Medical Director and Clinical Director to identify strengths as well as areas in need of improvement. It is further the policy of CID Management to work with the clinical peer reviewers at the time of the assessment to create a personal development plan that the clinical peer reviewers shall endeavor to complete prior to the following scheduled assessment. 5.0 Definitions Definitions of terms are set forth in Policy Procedures

206 6.1 The Clinical Director or Senior Clinical Staff shall conduct periodic assessments for each clinical peer reviewer. The periodic assessments shall occur with reference to the following intervals: At the 3 month anniversary with CID At the 6 month anniversary with CID At the 1 year anniversary with CID, and yearly thereafter. 6.2 The scheduled assessment will include consideration of reviews on which the initial reviewer worked, using the attached form to grade their performance. The performance assessment forms will be completed by the Clinical Director or Senior Clinical Staff. Whenever possible, a minimum of 5 reviews on which the clinical peer reviewer worked should be considered during each assessment interval. 6.3 As review assessments are completed, the Clinical Director or Senior Clinical Staff member who completed the assessment shall provide the assessment form and the draft assessed to the clinical peer reviewer, with explanations of all noted issues. The Clinical Director or Senior Clinical Staff member who completed the assessment shall invite the initial reviewer to discuss any questions or concerns regarding the assessment; and shall be available for such discussion. 6.4 In the event that an initial reviewer is noted to have similar performance issues on a consistent or repetitive basis, the Clinical Director or Director of Clinical Training and Assessment shall make available appropriate re-training resources. 6.5 The Clinical Director or Director of Clinical Training and Assessment shall place a copy of each assessment form in the clinical peer reviewer s personnel file

207 Clinical Peer reviewer: CID Review #: State/Jurisdiction: CID Management Clinical Peer Reviewer Assessment Form Date of Assessment: Assessment Performed by: (4 = excellent/yes;3 = very good;2 = good; 1 = poor;0 = very poor/no) Requests for Information, if applicable Request clearly outlines the info required from the provider N/A Request is for info reasonably necessary to make the determination N/A Request is for info not previously available through the CID system N/A Clinical Rationale Reviewer appears to have considered determinations in past reviews 4 0 N/A Reviewer appears to have considered all documents received on claim 4 0 Rationale contains basic claim demographics 4 0 Rationale clearly states the requested service and/or procedure 4 0 Rationale clearly states the determination 4 0 Rationale contains relevant history of care to date, if provided 4 0 N/A Rationale contains relevant patient subjective and objective findings Rationale provides a clear and concise systematic argument outlining logic used to make determination of medical necessity Rationale is not based on non-industrial causation or billing factors Reviewer s determination demonstrates appropriate use of evidence based medicine approach clinical expertise, patient response to care & scientific/guidelines evidence Guidelines Reviewer referenced state mandated guidelines first 4 0 Guidelines selection was concise 4 0 Appropriate guidelines were cited to support the clinical rationale position Guidelines selection was specific to the diagnosis and requested treatment Migrating Review Reviewer had appropriate rationale for migrating the review to the next appropriate person (e.g. ICR; QAQC reviewer) 4 0 Timelines Reviewed completed review in appropriate time frame 4 0 Spelling/Organization Spelling, grammar, construction of paragraphs appropriate Total (if AMI involved): / 80 Total (no AMI involved): / 68 Overall impression & Notes:

208 Delegation of Clinical Peer Review Functions CID Management Policy No Revision: 1.0 Revision Date: 5/14/2009 Page 1 of 7 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines establishing requirements for delegation of functions performed by clinical peer reviewers to a non-cid vendor. 2.0 Revision History Revision /20/2008 New Policy & Form/Initial Implementation Revision /14/2009 Revised Revision /08/2010 Reviewed Revision /26/2011 Reviewed Revision /06/2012 Reviewed 3.0 Persons Affected This policy affects all clinical staff employed by vendors under contract with CID to perform functions that are components of a clinical peer review. 4.0 Policy The policy of CID Management is to ensure that all clinical peer review functions performed on behalf of CID by a contracted vendor complies with all requirements and criteria applied to work performed by clinical peer reviewers employed by CID. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 Upon identification of a potential vendor for providing functions performed by clinical peer reviewers, the Clinical Director shall verify that the vendor holds current non-conditional accreditation by URAC for CORE standards

209 6.2 Prior to contractual agreement for delegation of clinical peer review functions, the CID Committee on Policies and Procedures shall review the policies and procedures of the potential vendor. The Committee on Policies and Procedures shall report its findings to all CID Directors, and those findings must at minimum indicate that the vendor is in full compliance with CID polices and procedures, or must specifically identify any areas of potential non-compliance Potential vendors must have a policy that prohibits any system for reimbursement, bonuses, or incentives to staff based directly or indirectly on consumer utilization of health care services. 6.3 The Committee on Policies and Procedures shall obtain and review current policies and procedures of each vendor contractually performing delegated clinical peer review functions at least annually, and shall perform a limited review in the event that the vendor advises CID of a material change in the manner or method of performing delegated functions. The Committee on Policies and Procedures shall report its findings to all CID Directors, and those findings must at minimum indicate that the vendor is in full compliance with CID polices and procedures, or must specifically identify any areas of potential non-compliance. 6.4 Delegated clinical peer review functions must be governed by a written contractual agreement. All such written contracts must conform to the following criteria: All clinical peer review functions which may be delegated to the vendor must be specified, and must be consistent with CID Policy 3300 (Clinical Peer Review) All clinical functions which may not be designated to the vendor must be specified. Clinical functions specifically excluded must be consistent with CID Policy 3300 (Clinical Peer Review). Any functions related to domains identified by the Committee on Policies and Procedures as noncompliant with CID policies and procedures must also be excluded Contract must specify that vendor must perform all delegated functions in accordance with CID policies and procedures and URAC standards Vendor must be required to report any material change in the manner or method of performing delegated functions prior to enacting such change Contract must specify that CID may conduct surveys of the vendor as required Contract must require that the vendor submit periodic reports to CID regarding the performance of its delegated responsibilities Contract must require that in the event of identified problems or noncompliance with either CID policies/procedures or URAC standards, that the vendor will cease performing delegated functions related to the identified problem until correction has been successfully implemented Contract must specify that no clinical peer review CID functions or work may be further delegated or subcontracted to another party or vendor

210 6.4.9 Contract must specify that all delegated clinical peer review functions or work will be completed via the CID s proprietary medical management system and database Contract must specify that each person directly involved in performing delegated clinical peer review functions must be vetted by the CID Credentialing Committee prior to performing those functions, including provision of a copy of a valid clinical license; documentation of malpractice insurance coverage; a copy of a curriculum vitae, including education and history of providing direct patient care; non-disclosure agreement; a HIPAA agreement; and a conflict of interest form Contract must specify that the vendor will provide certification for each person involved in performing delegated clinical peer review functions has no history of revocation, suspension or limitation to practice their health care discipline; no sanction or disciplinary action within the past five years by their licensing board; no history of malpractice claims or convictions; and no history of felony convictions Contract must specify that any person deemed by the CID Credentialing Committee to be unqualified or unsuitable as a clinical peer reviewer shall be prohibited from performing any delegated functions of clinical peer review on behalf of CID Contract must specify that documentation described in and shall be provided to the CID Credentialing Committee at least annually for re-credentialing of each person performing delegated clinical peer review functions Contract must specify that all persons directly involved in performing delegated clinical peer review functions must be provided with all jobspecific training materials available to CID clinical peer reviewers. 6.5 The Clinical Director shall perform periodic assessments for each vendor staff member performing delegated clinical peer review functions. These periodic assessments shall occur, at minimum, at the following times: After 3 months of performing delegated clinical peer review functions for CID After 6 months of performing delegated clinical peer review functions for CID After 1 year of performing delegated clinical peer review functions for CID, and yearly thereafter. 6.6 The assessment of vendor staff undertaken by the Clinical Director shall consist of review of a minimum of 5 reviews on which the vendor staff member worked, using the attached form to grade their performance

211 6.7 The Clinical Director shall incorporate the outcomes of vendor staff assessment into annual reporting to the QAQC Committee. 6.8 No clinical peer review functions shall be delegated for emergency, urgent, expedited or concurrent reviews. 6.9 All reviews for which clinical peer reviewer functions have been delegated to a non- CID contracted vendor shall be verified for correctness and accuracy by a CID QAQC reviewer prior to release of any determination letters

212 Addendum State of Massachusetts 1.0 The credentialing process shall further verify that clinical peer reviewers practice a minimum of 8 hours per week if they will be performing utilization management functions on claims originating in the Commonwealth of Massachusetts

213 Addendum State of Tennessee 1.0 The credentialing process shall further verify that clinical peer reviewers are physicians who are licensed and domiciled in Tennessee

214 Addendum State of Texas 1.0 The credentialing process shall further verify that clinical peer reviewers who are doctors are licensed to practice in Texas

215 Clinical Peer reviewer: CID Review #: State/Jurisdiction: Clinical Peer Reviewer Review-Specific Assessment Date of Assessment: Assessment Performed by: (4 = excellent/yes;3 = very good;2 = good; 1 = poor;0 = very poor/no) Requests for Information, if applicable Request clearly outlines the info required from the provider N/A Request is for info reasonably necessary to make the determination N/A Request is for info not previously available through the CID system N/A Clinical Rationale Reviewer appears to have considered determinations in past reviews 4 0 N/A Reviewer appears to have considered all documents received on claim 4 0 Rationale contains basic claim demographics 4 0 Rationale clearly states the requested service and/or procedure 4 0 Rationale clearly states the determination 4 0 Rationale contains relevant history of care to date, if provided 4 0 N/A Rationale contains relevant patient subjective and objective findings Rationale provides a clear and concise systematic argument outlining logic used to make determination of medical necessity Rationale is not based on non-industrial causation or billing factors Reviewer s determination demonstrates appropriate use of evidence based medicine approach clinical expertise, patient response to care & scientific/guidelines evidence Guidelines Reviewer referenced state mandated guidelines first 4 0 Guidelines selection was concise 4 0 Appropriate guidelines were cited to support the clinical rationale position Guidelines selection was specific to the diagnosis and requested treatment Migrating Review Reviewer had appropriate rationale for migrating the review to the next appropriate person (e.g. ICR; QAQC reviewer) 4 0 Timelines Reviewed completed review in appropriate time frame 4 0 Spelling/Organization Spelling, grammar, construction of paragraphs appropriate Total (if AMI involved): / 80 Total (no AMI involved): / 68 Overall impression & Notes:

216 QAQC Reviewer Credentialing CID Management Policy No Revision: 3.2 Revision Date: 3/11/2011 Page 1 of 5 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which QAQC reviewers contracted with CID to perform utilization management operations are credentialed. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /20/2008 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /27/2011 Reviewed Revision /11/2011 Revised Revision /22/2012 Revised 3.0 Persons Affected This policy affects all QAQC reviewers contracted with CID to perform utilization management operations. 4.0 Policy The policy of CID Management is to perform credentialing on all QAQC reviewers upon initial contracting. It is further the policy of CID Management to perform re-credentialing on all QAQC reviewers on a yearly basis. 5.0 Definitions Definitions of terms are set forth in Policy Procedures

217 6.1 If, following the interview process, CID has determined that the candidate is a viable choice for the position and that a contract offer is desired, prior to making a contract offer the Recruiter of Clinical Personnel shall perform an initial credentialing check. 6.2 The initial credentialing check by the Recruiter of Clinical Personnel shall include primary source verification as appropriate including any, or all, of the following: State licensing boards -- validating the practitioner's license to practice and confirming whether there are any sanctions against the license Schools/training programs - validating the practitioner's highest level of training in his/her specialty and validating board certification status with the American Board of Medical Specialties National Technical Information Service (NTIS) -- validating the practitioner's license to prescribe drugs. The certificates reviewed are the Drug Enforcement Agency (DEA) certificate or Controlled Drug Substance Registration (CDS) Medicare/Medicaid - determining whether sanctions have been imposed by the federal government's Office of Inspector General (OIG) or Office of Personnel Management (OPM) Malpractice history - reviewing claims history. 6.3 The Recruiter of Clinical Personnel shall evaluate to determine if the candidate meets the following inclusion criteria: Has undergone formal training in a health care field Holds an associates degree in a health care field, or holds a state license, or state certificate in a health care field, Has professional experience in providing direct patient care, Holds a current unrestricted license to practice in a health care field Has an acceptable malpractice history. 6.4 The Recruiter of Clinical Personnel shall also evaluate to determine if the candidate meets the following exclusion criteria: Has a history of revocation, suspension or limitation to practice their health care discipline, Has a sanction or disciplinary action within the past five years by their licensing board,

218 6.4.3 Has an unacceptable malpractice history, Has a history of felony convictions. 6.5 If, upon initial credentialing, the Recruiter of Clinical Personnel discovers that the candidate meets all inclusion criteria as outlined in CID Policy 2300, and does not meet any exclusion criteria as outlined in CID Policy 2300, the Recruiter of Clinical Personnel shall forward documentation from primary verification sources to the Director of Clinical Personnel. The Director of Clinical personnel shall also verify that the candidate meets all inclusion criteria from CID Policy 2300 and none of the exclusion from CID Policy 2300 The Director of Clinical Personnel shall conclude that the candidate has passed the credentialing process and shall disclose this information to the Recruiter of Clinical Personnel and Clinical Director. 6.6 If, upon initial credentialing, the Recruiter of Clinical Personnel or the Director of Clinical Personnel discovers any item that precludes the candidate from meeting all inclusion criteria as outlined in CID Policy 2300, or any item that matches any exclusion criteria as outlined in CID Policy 2300, the Recruiter of Clinical Personnel or the Director of Clinical Personnel shall conclude that the candidate has not passed the credentialing process and shall disclose this information to the Recruiter of Clinical Personnel; the Director of Clinical Personnel; and Clinical Director. The party providing such disclosure shall further indicate the principle reason(s) the candidate did not pass the credentialing process. 6.7 If the candidate successfully passed the credentialing process, the Recruiter of Clinical Personnel; the Director of Clinical Personnel; or the Clinical Director shall contact the candidate with a contract offer. 6.8 If the candidate has not passed the credentialing process, the Director of Clinical Personnel or Clinical Director shall contact the candidate to inform him/her that no contract offer will be made and provide the candidate of the principle reason(s) he/she did not pass the credentialing process. 6.9 The candidate shall have the opportunity to respond to the principle reason(s); however in absence of proving the unsuccessful attempt at credentialing was due to incorrect information, the credentialing decision shall stand The Director of Clinical Personnel shall insure that a re-credentialing of all initial clinical reviewers is performed by the Director of Clinical Personnel or a Recruiter of Clinical Personnel at regular intervals, not to exceed 1 year and no later than scheduled expiration of licensure/certification. The performance of this credentialing shall include primary source verification as appropriate including any, or all, of the following:

219 State licensing boards -- validating the practitioner's license to practice and confirming whether there are any sanctions against the license Validating board certification status with the American Board of Medical Specialties National Technical Information Service (NTIS) -- validating the practitioner's license to prescribe drugs. The certificates reviewed are the Drug Enforcement Agency (DEA) certificate or Controlled Drug Substance Registration (CDS) Medicare/Medicaid - determining whether sanctions have been imposed by the federal government's Office of Inspector General (OIG) or Office of Personnel Management (OPM) Malpractice history - reviewing claims history The periodic re-credentialing evaluation shall determine if the initial clinical reviewer continues to meet all of the inclusion criteria from CID Policy 2300; and shall determine that the initial clinical reviewer meets none of the exclusion criteria from CID Policy If, upon re-credentialing, the Director of Clinical Personnel or a Recruiter of Clinical Personnel discovers that the QAQC reviewer meets all inclusion criteria as outlined in CID Policy 2300, and does not meet any exclusion criteria as outlined in CID Policy 2300, the Director of Clinical Personnel or a Recruiter of Clinical Personnel shall conclude that the QAQC reviewer has passed the credentialing process and shall document this in the QAQC reviewer s personnel file If, upon re-credentialing, the Director of Clinical Personnel or a Recruiter of Clinical Personnel discovers any item that precludes the QAQC reviewer from meeting all inclusion criteria as outlined in CID Policy 2300, or any item that matches any exclusion criteria as outlined in CID Policy 2300, the Director of Clinical Personnel or a Recruiter of Clinical Personnel shall conclude that the QAQC reviewer has not passed the credentialing process and shall disclose this information to the Director of Clinical Personnel and the Clinical Director. Such disclosure shall further include the principle reason(s) the QAQC reviewer did not pass the re-credentialing process If the QAQC reviewer has not passed the re-credentialing process, the Medical Director or Clinical Director shall contact the QAQC reviewer to inform him/her that his/her contract will be terminated and provide the QAQC reviewer of the principle reason(s) he/she did not pass the credentialing process The QAQC reviewer shall have the opportunity to respond to the principle reasons, however in absence of proving the unsuccessful attempt at re-credentialing

220 was due to incorrect information, the credentialing decision and contract termination shall stand

221 QAQC Reviewer Initial Paperwork CID Management Policy No Revision: 3.0 Revision Date: 3/16/2011 Page 1 of 3 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines for paperwork required to be signed by QAQC reviewer prior to being contracted with CID to perform utilization management operations. 2.0 Revision History Revision /15/2006 New Policy and Forms/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /27/2011 Reviewed Revision /16/2011 Revised Revision /22/2012 Revised 3.0 Persons Affected This policy affects all QAQC reviewer members contracted by CID to perform utilization management operations. 4.0 Policy The policy of CID Management is to require the following items to be completed by all QAQC reviewer members contracted by CID to perform utilization management operations prior to commencement of the contractor relationship: 4.1 QAQC reviewer contract 4.2 Non-disclosure agreement 4.3 CID/business associate HIPAA agreement 4.4 Conflict of interest form

222 4.5 W9 or W2, as applicable It is further the policy of CID Management to require the following items be submitted by all QAQC reviewers contracted by CID to perform utilization management operations prior to commencement of the contractor relationship: 4.6 Copy of current health care provider licenses 4.7 Listing of all active and inactive health care provider licenses ever held 4.8 Copy of current malpractice insurance policy coversheet 4.9 Disclosure of all prior disciplinary actions taken by health care licensing boards as well as any prior malpractice actions Completed Electronic Signature Form. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 Upon official offer of an contractor position, CID shall request the candidate provide the following documents: Copy of current curriculum vitae, if available Copy of current health care provider licenses Listing of all active and inactive health care provider licenses ever held Copy of current malpractice insurance policy coversheet Disclosure of all prior disciplinary actions taken by health care licensing boards as well as any prior malpractice actions Completed Electronic Signature Form. 6.2 Upon official offer of an contractor position, CID shall provide the candidate with a copy of, and shall review, explain and answer any questions from the candidate regarding the following documents: QAQC reviewer contract Non-disclosure agreement

223 6.2.3 CID/business associate HIPAA agreement Conflict of interest form W9 or W2, as applicable 6.3 The candidate shall have all the time they feel they require to review the documents and ask questions of CID. 6.4 Upon receipt of all documents listed in 6.1 and receipt of all completed documents listed in section 6.2, the contractor shall begin employment at CID

224 QAQC Reviewer Training CID Management Policy No Revision: 4.0 Revision Date: 1/29/2008 Page 1 of 3 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines for training provided to QAQC reviewers contracted with CID to perform utilization management operations. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /24/2006 Addition of training in URAC standards Revision /26/2006 Revised Revision /05/2007 Revised Revision /29/2008 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /27/2011 Reviewed Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all QAQC reviewers contracted with CID to perform utilization management operations. 4.0 Policy The policy of CID Management is to provide QAQC reviewers, contracted with CID to perform utilization management operations, with the following training sessions: 4.1 Introduction to CID 4.2 Introduction to workers compensation 4.3 Introduction to utilization management Overview of utilization management

225 4.3.2 Labor code, regulations, and case law regarding utilization management CID s utilization management process URAC utilization management standards 4.4 Conflict of interest policies and procedures 4.5 Confidentiality policies and procedures 4.6 Job specific training 4.7 Periodic Training Updates as required including: Changes to the CID utilization management process Changes to labor code, regulations, or case law regarding utilization management 4.8 Training on identification and prevention of fraud and abuse, as appropriate to job functions 4.9 Re-Training on an annual basis. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 Upon hire, the Clinical Director or Senior Clinical Staff shall schedule the following training sessions for the new QAQC reviewer contractor: Introduction to CID Introduction to workers compensation Introduction to utilization management Overview of utilization management Labor code, regulations, and case law regarding utilization management CID s utilization management process

226 URAC utilization management standards Conflict of interest policies and procedures Confidentiality policies and procedures Job specific training Identification of fraud and abuse 6.2 Completion of each training session in section 6.1 shall be logged into the QAQC reviewer s personnel file by the Clinical Director or Senior Clinical Staff. 6.3 As needed, the Clinical Director or Senior Clinical Staff shall schedule periodic training updates for all QAQC reviewers. 6.4 Completion of periodic training updates may be logged into the QAQC reviewer s personnel file at the discretion of the Clinical Director or Senior Clinical Staff. 6.5 If the Clinical Director or Senior Clinical Staff notes an area of performance in which the QAQC reviewer is not adhering to CID s policies and procedures, or in which the job duties are being performed in an unacceptable fashion, the Clinical Director or Senior Clinical Staff shall schedule re-training. The reason for the re-training shall be logged into the QAQC reviewer s personnel file by the Clinical Director or Senior Clinical Staff. 6.6 Completion of each re-training session shall be logged into the QAQC reviewer s personnel file by the Clinical Director or Senior Clinical Staff. 6.7 If QAQC committee notes an area of performance in which the QAQC reviewer is not adhering to CID s policies and procedures, or in which the job duties are being performed in an unacceptable fashion, they shall communicate this to the QAQC reviewer and the Clinical Director or Senior Clinical Staff. The Clinical Director or Senior Clinical Staff shall schedule re-training. The reason for the re-training shall be logged into the QAQC reviewer s personnel file by the Clinical Director or Senior Clinical Staff. 6.8 Completion of each re-training session shall be logged into the QAQC reviewer s personnel file by the Clinical Director or Senior Clinical Staff

227 QAQC Reviewer Assessment CID Management Policy No Revision: 4.1 Revision Date: 3/11/2011 Page 1 of 3 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which QAQC reviewers shall undergo assessment. 2.0 Revision History Revision /15/2006 New Policy and Forms/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /14/2009 Revised Revision /08/2010 Reviewed Revision /27/2011 Reviewed Revision /11/2011 Revised Revision /22/2012 Revised 3.0 Persons Affected This policy affects all QAQC reviewers employed by, or contracted with, CID Management. 4.0 Policy The policy of CID Management is to perform ongoing assessment of QAQC reviewers to identify strengths as well as areas in need of improvement. It is further the policy of CID Management to work with the QAQC reviewers at the time of the assessment to create a personal development plan that the QAQC reviewers shall endeavor to complete prior to the following scheduled assessment. 5.0 Definitions Definitions of terms are set forth in Policy Procedures

228 6.1 The Clinical Director or Senior Clinical Staff shall conduct periodic assessments for each QAQC reviewer. The periodic assessments shall occur with reference to the following intervals: At the 3 month anniversary with CID At the 6 month anniversary with CID At the 1 year anniversary with CID, and yearly thereafter. 6.2 The scheduled assessment will include consideration of reviews on which the initial reviewer worked, using the attached form to grade their performance. The performance assessment forms will be completed by the Clinical Director or Senior Clinical Staff. Whenever possible, a minimum of 5 reviews on which the QAQC reviewer worked should be considered during each assessment interval. 6.3 As review assessments are completed, the Clinical Director or Senior Clinical Staff member who completed the assessment shall provide the assessment form and the draft assessed to the QAQC reviewer, with explanations of all noted issues. The Clinical Director or Senior Clinical Staff member who completed the assessment shall invite the initial reviewer to discuss any questions or concerns regarding the assessment; and shall be available for such discussion. 6.4 In the event that an initial reviewer is noted to have similar performance issues on a consistent or repetitive basis, the Clinical Director or Director of Clinical Training and Assessment shall make available appropriate re-training resources. 6.5 The Clinical Director or Director of Clinical Training and Assessment shall place a copy of each assessment form in the QAQC reviewer s personnel file

229 QAQC reviewer: CID Review #: State/Jurisdiction: CID Management QAQC reviewer Assessment Form Date of Assessment: Assessment Performed by: (4 = excellent/yes;3 = very good;2 = good; 1 = poor;0 = very poor/no) Document Summaries Ensured document summaries used in clinical rationale were error free 4 0 Clinical Rationale Ensured rationale contains basic claim demographics 4 0 Ensured rationale clearly states the requested service and/or procedure 4 0 Ensured rationale clearly states the determination 4 0 Ensured match of rationale language and rationale selection button 4 0 Ensured rationale contains relevant history of care to date, if provided 4 0 Ensured rationale contains relevant patient subjective and objective findings Ensured rationale provides a clear and concise systematic argument outlining logic used to make determination of medical necessity Ensured reviewer s determination demonstrated appropriate use of evidence based medicine approach Guidelines Ensured reviewer referenced state mandated guidelines first 4 0 Ensured guidelines selection was concise 4 0 Ensured appropriate guidelines were cited to support the clinical rationale Ensured guidelines selection was specific to the diagnosis and treatment Migrating Review Reviewer had appropriate rationale for migrating the review to the next appropriate person (e.g. released to stakeholders; return to CPR) 4 0 Timelines Reviewed completed review in appropriate time frame 4 0 Spelling/Organization Ensured spelling, grammar, construction of paragraphs appropriate Overall impression & Notes: Total (no AMI involved): /

230 Delegation of QA/QC Review Functions CID Management Policy No Revision: 1.0 Revision Date: 4/20/2008 Page 1 of 1 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines establishing requirements for delegation of functions performed by QA/QC reviewers to a non-cid vendor. 2.0 Revision History Revision / New Policy & Form/Initial Implementation Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /27/2011 Reviewed Revision /22/2012 Reviewed 3.0 Persons Affected This policy affects all QAQC reviewers contracted with CID to perform utilization management operations. 4.0 Policy The policy of CID Management is to ensure that all QA/QC review functions will be performed by QA/QC reviewers employed by CID. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 There shall be no contractual delegation of QA/QC review functions to any vendor. All such functions shall be provided by QA/QC reviewers employed by CID

231 Receipt of Request For Authorization CID Management Policy No Revision: 4.1 Revision Date: 3/11/2011 Page 1 of 5 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which CID may receive requests for authorization. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /29/2008 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /11/2011 Revised Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects CID non-clinical administrative staff whose job duties include receipt of requests for utilization management services. 4.0 Policy The policy of CID Management is to allow clients to specify whether requests for authorization may only be processed if received from the claim administrator directly or if they may be processed if received from any other stakeholder which may include, but is not limited to: the requesting physician, the claims adjustor, the facility rendering the service, the provider, or a state regulator. CID reserves the right to edit the client s list to comply with any applicable state labor code or regulation. 5.0 Definitions Definitions of terms are set forth in Policy Procedures

232 6.1 CID clients may choose to have requesting physician submit requests for authorizations and appeals considerations directly to the claims administrator or directly to CID 6.2 CID shall not initiate reviews unless specifically requested by the client or by a party authorized to do so by the client. 6.3 In the case where the client has authorized a party to submit requests for authorization directly to CID, CID shall ensure that the frequency of reviews does not exceed that which is appropriate based upon the severity or complexity of the patient s condition, or on necessary treatment and discharge planning. If the frequency of reviews appears to exceed that which is appropriate based upon the severity or complexity of the patient s condition, or on necessary treatment and discharge planning, CID shall contact the claims administrator to determine if the review shall or shall not be started. 6.4 Should the client choose to have requests for authorization and appeals considerations submitted directly to the claims administrator, the client shall ensure the following: The claims administrator shall maintain phone access from 9:00 AM to 5:30 PM local time on normal business days for providers to request authorization for medical services or submit appeals considerations The claims administrator shall maintain a process to receive communications from health care providers requesting authorization for medical services or appeals considerations after business hours which may be satisfied by maintaining a voice mail system or facsimile number The claims administrator shall forward the request for authorization and appeals considerations for which they are requesting utilization management to CID, via means specified by CID, within two days of receipt. Designated means many include, but are not limited to, secured web portal, facsimile, secured electronic transmission, US postal service, or courier service. 6.5 Should the client choose to have requests for authorization, appeals considerations and re-considerations submitted directly to CID by any stakeholder, then: The claims administrator shall provide CID a list of stakeholders who may submit requests. The claims administrator shall further instruct providers to submit requests for authorization and appeals considerations directly to CID The claims administrator shall make CID s toll free telephone number and fax number available to providers

233 6.5.3 Each claims administrator shall record a message on their voice mail message directing parties to submit requests for authorization and appeals considerations directly to CID and provide CID s toll free telephone number and fax number CID shall maintain phone access from 9:00 AM to 5:30 PM in all time zones in which CID conducts utilization management functions, on normal business days for parties to request authorization for medical services and appeals considerations CID shall maintain a process to receive communications from parties requesting authorization for medical services and appeals considerations after business hours which may be satisfied by maintaining a voice mail system or facsimile number. 6.6 Written requests for authorization shall be deemed to have been received by facsimile on the date the request was received if the receiving facsimile electronically date stamps the transmission. If there is no electronically stamped date recorded, then the date of receipt shall be deemed to be the date the request was transmitted. A request for authorization transmitted by facsimile after 5:30 P.M. local time shall be deemed to have been received on the following business day. 6.7 Where the request for authorization is received by mail and a proof of service by mail exists, the request shall be deemed to have been received five (5) days after the deposit in the mail at a facility regularly maintained by the United States Postal Service. Where the request is delivered via certified mail, return receipt mail, the request shall be deemed to have been received on the receipt date entered on the return receipt. In the absence of a proof of service by mail or a dated return receipt, the request shall be deemed to have been received on the date the documentation was uploaded to the CID system (e.g., electronic date stamp)

234 Addendum State of California 1) Written requests for authorization shall be deemed to have been received by facsimile on the date the request was received if the receiving facsimile electronically date stamps the transmission. If there is no electronically stamped date recorded, then the date of receipt shall be deemed to be the date the request was transmitted. A request for authorization transmitted by facsimile after 5:30 P.M. local time shall be deemed to have been received by the claims administrator on the following business day as defined in CA Labor Code section and in section 9 of the CA civil Code. 2) Where the request for authorization is received by mail and a proof of service by mail exists, the request shall be deemed to have been received five (5) days after the deposit in the mail at a facility regularly maintained by the United States Postal Service. Where the request is delivered via certified mail, return receipt mail, the request shall be deemed to have been received on the receipt date entered on the return receipt. In the absence of a proof of service by mail or a dated return receipt, the request shall be deemed to have been received on the date stamped on the document by the recipient 3) Authorization or utilization review must be completed for every request for authorization (as defined by 8CCR9792.6(o)) received, consistent with the requirements of LC4610 and 8CCR The process described in Policy 3000, section 6.3, shall not be applied to claims within the California jurisdiction

235 Addendum State of Massachusetts 1.0 Consistent with 452 CMR 6.02 (4)(e), the worker shall be considered a stakeholder authorized to submit requests for continued care/services directly to CID for utilization management functions on claims originating in the Commonwealth of Massachusetts

236 Telephonic Inquiry Regarding Utilization Management Services CID Management Policy No Revision: 3.0 Revision Date: 6/5/07 Page 1 of 2 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which telephonic inquiries regarding utilization management services shall be addressed. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /14/2011 Reviewed Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects CID non-clinical administrative staff whose job duties include answering telephone calls and s which may include inquiries regarding the utilization management process. 4.0 Policy The policy of CID Management is to train the non-clinical administrative staff to respond to non-clinical questions regarding the utilization management process. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 Upon receipt of a non-clinical question regarding the utilization management process, non-clinical administrative staff shall respond to the inquiry giving as much detail as

237 required to satisfy the inquiry. The response shall not violate CID s confidentiality policy. 6.2 Should the inquiry exceed the knowledge of the non-clinical administrative staff member, the communication shall be transferred to the Director of Production for response. The Director of Production shall respond to the inquiry giving as much detail as required to satisfy the inquiry. The response shall not violate CID s confidentiality policy. 6.3 Should the inquiry exceed the knowledge of the Director of Production, the communication shall be transferred to the Clinical Director for response. The Clinical Director shall respond to the inquiry giving as much detail as required to satisfy the inquiry. The response shall not violate CID s confidentiality policy. 6.4 Upon receipt of a clinical question regarding the utilization management process, non-clinical administrative staff shall forward the inquiry to the Clinical Director for response. 6.5 Upon receipt of a clinical question regarding the utilization management process, the Clinical Director shall respond to the inquiry giving as much detail as required to satisfy the inquiry. The response shall not violate CID s confidentiality policy. 6.6 Alternatively, the Clinical Director may defer the response to the initial clinical reviewer or clinical peer reviewer who performed the original review. The initial clinical reviewer or clinical peer reviewer would then respond to the inquiry giving as much detail as required to satisfy the inquiry. The response shall not violate CID s confidentiality policy

238 Utilization Management Electronic Review File CID Management Policy No Revision: 3.0 Revision Date: 6/5/07 Page 1 of 6 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines for the electronic review file. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /14/2011 Reviewed Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects CID non-clinical administrative staff and clinical staff. 4.0 Policy The policy of CID Management is to create an electronic review file for each request for authorization, appeals consideration, or re-consideration received. It is further the policy of CID Management to capture all information and documents relevant to the request for authorization, appeals determination, or re-consideration as a component of the electronic review file. It is further the policy of CID Management to create a link between reviews for a given claim to allow reviewers access to all prior information received on a claim to avoid duplicate requests for information from providers. 5.0 Definitions Definitions of terms are set forth in Policy Procedures

239 6.1 Once a request for authorization, appeals consideration, or re-consideration has been submitted to CID, the non-clinical administrative staff shall evaluate the submission using the following steps: If the request for authorization or appeals consideration has been submitted to CID directly from the claims administrator, the non-clinical administrative staff shall: Review the information submitted to ensure that the claims administrator has provided the necessary information required to create an electronic review file. The necessary information may include, but is not limited to: Compensability of the claim Patient demographic information, Provider demographic information, Applicant attorney demographic information, Defense attorney demographic information, Workers compensation claim demographic information, Pre-review screening information collected by the client, Specific request for authorization or appeals consideration for which the client is requesting utilization management If the necessary information is not present, the non-clinical administrative staff shall contact the claim administrator to request the additional information. This communication may occur via phone call, electronic means, or fax, and shall be logged into the CID system If the requested additional information is received, the non-clinical administrative staff shall proceed to point If the requested additional information is not received within 1 business day, the non-clinical administrative staff shall contact the claim administrator again to

240 request the additional information. This communication may occur via phone call, electronic means, or fax, and shall be logged into the CID system. Contacts will be made at a frequency of 1 time per day until the necessary information is received If the necessary information is present, the non-clinical administrative staff shall utilize the CID secured web-site and proprietary software to create an electronic review file for the request for authorization, appeals consideration, or reconsideration Based on the specific medical discipline of the review, the CID system shall automatically assign the review to the appropriate initial clinical reviewer or to a clinical peer reviewer based upon criteria set forth by the Medical and/or Clinical Directors If the request for authorization or appeals consideration has been submitted to CID directly from any party other than the claims administrator, the non-clinical administrative staff shall: Verify that the party submitting the request is permitted to do so as per CID policies or the contract with the client, taking into consideration CID s right to edit this list to comply with state labor code and regulations If the party is permitted to do so, the non-clinical administrative staff member shall proceed to If the party is not permitted to do so, then the nonclinical administrative staff member shall contact the submitting party and inform them that client has not authorized CID to receive requests from that party and that they must contact the claims administrator directly Log onto the client s electronic claims management system via secured link to gather the following information: Compensability of claim Patient demographic information, Provider demographic information, Applicant attorney demographic information,

241 Defense attorney demographic information, Workers compensation claim demographic information Review the information submitted to ensure that the provider has clearly outlined the specific course of proposed medical treatment for which authorization or appeals consideration was requested If the specific course of proposed medical treatment for which authorization or appeals consideration was requested is not clear, the non-clinical administrative staff shall utilize the CID secured web-site and proprietary software to create an electronic review file for the request for authorization or appeals consideration. Using the CID software, the non-clinical administrative staff member shall then fax the provider requesting clarification of the specific course of proposed medical treatment for which authorization or appeals consideration was requested If the specific course of proposed medical treatment for which authorization or appeals consideration was requested is clear, the non-clinical administrative staff shall utilize the CID secured website and proprietary software to create an electronic review file for the request for authorization or appeals consideration Based on the specific medical discipline of the review, the CID system shall automatically assign the review to the appropriate initial clinical reviewer or to a clinical peer reviewer based upon criteria set forth by the Medical and/or Clinical Directors 6.2 The electronic review file shall contain: A specific review number The type and category of the review The names, contact information, and relationship to the review for each review stakeholder including, but not limited to: Patient Patient s legal counsel Claims administrator Client appointed personnel including, but not limited to:

242 Claims assistants Claims supervisor Medical management staff Defense legal counsel Requesting physician Attending physician Secondary physicians Non-physician providers of goods and/or services Non-clinical administrative staff member Initial clinical reviewer Clinical peer reviewer QAQC reviewer All relevant dates for the review including, but not limited to: Date client received request Date claims administrator requested additional information, if applicable Date claims administrator received additional information, if applicable Date CID received request Date CID requested additional information, if applicable Date CID received additional information, if applicable Date review was placed on hold, if applicable Date review was released from hold, if applicable Dates administrative processing of review began and ended

243 Dates initial clinical review began and ended Dates clinical peer review began and ended Dates QAQC review began and ended Date request was released to the client Date request was released to all stakeholders Date request was withdrawn, if applicable All documents received for the review All documents generated for the review by CID All activities performed on the review including, but not limited to: Creation of review Uploading of any documents Generation of any documents Distribution of any correspondences Receipt of any communications including , telephone calls, faxes, or mail Initiation of any s, telephone calls, faxes or mail Record of discussion with any person via telephone Copy of any sent or received A link to all previous reviews completed on the claim, and a link to all previous documents received for the claim, to provide the clinical staff access to all previous documents received in order to avoid duplicate requests for information from providers

244 Pre-Review Screening CID Management Policy No Revision: 4.1 Revision Date: 5/14/2012 Page 1 of 5 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which pre-review screening may be done. 2.0 Revision History Revision /15/2006 New Policy and Form/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /14/2011 Reviewed Revision /11/2011 Revised Revision /24/2012 Reviewed Revision /14/2012 Revised 3.0 Persons Affected This policy affects all CID employees and contractors whose job duties include pre-review screening. 4.0 Policy The policy of CID Management is to allow non-clinical administrative staff to perform prereview screening provided that that pre-review screening is limited to the collection of nonclinical data or provided that the collection of clinical data occurs following scripts approved by the CID medical director. It is further the policy of CID Management that noncertifications shall not be issued solely on the basis of pre-review screening. 5.0 Definitions Definitions of terms are set forth in Policy Procedures

245 6.1 The Medical Director and Clinical Director shall create the pre-review screening script and shall revise it as deemed necessary. This shall be done on a frequency of not less than annually. 6.2 A copy of the pre-review screening script shall be provided to each non-clinical administrative staff employee or contractor who may be required to perform prereview screening as a component of their job duties. 6.3 The Medical Director or Clinical Director shall ensure that each non-clinical administrative staff employee or contractor who may be required to perform prereview screening as a component of their job duties is trained on how to perform prereview screening. 6.4 A Senior Clinical staff member, or the Clinical Director, shall be available to monitor any non-clinical administrative staff member who performs pre-review screening. 6.5 Once the request for authorization has been received by CID, CID non-clinical administrative staff may perform pre-review screening and, if so, shall ensure that: Pre-review screening occurs within 2 business days of receiving the request for authorization, appeals consideration, or re-consideration Pre-review screening shall include any of the following: Collection of structured clinical data defined as clinical information that is precise and permits exact matching against explicit medical terms, diagnoses or procedure codes, or other explicit choices, without the need for interpretation, Asking scripted clinical questions, Accepting responses to scripted clinical questions, In the event that the request for authorization consists only of financial documentation (e.g., billing, liens, demand for payment, etc.); and includes no medical reporting of any kind; non-clinical administrative staff may issue a written request for information by using the pre-review script for written requests for medical documentation Pre-review screening shall not include any of the following: Applying clinical judgment or interpretation, Accepting unstructured clinical information,

246 Deviating from script, Engaging in unscripted clinical dialogue, Asking clinical follow up questions, Issuing non-certifications The information gathered in pre-review screening is recorded in the CID utilization management electronic review file and the review shall be assigned to either an initial clinical reviewer or a clinical peer reviewer

247 CID Management Pre-Review Screening Script NOTE: You may not ask questions that call for: o Applying clinical judgment or interpretation, o Accepting unstructured clinical information, o Deviating from script, o Engaging in unscripted clinical dialogue, o Asking clinical follow up questions, o Issuing non-certifications. My name is and I am a(n) (job title) working at CID Management. We have received a request for (authorization / appeals consideration / re-consideration) from (physician) on the claim for (patient). In order to start the review for this request, we require the following additional information: Patient Demographics: Patient first and last names, date of birth, social security number, contact information Provider Demographics Provider first and last names, degree, specialty, federal tax id number, license number, contact information Claim Demographics Claim number and/or date of injury Adjustor name and contact information (company, address, phone, fax, ) Medical Information Scripted Questions 1. Can you please provide the patient diagnoses including ICD9 codes? 2. Can you please verify the primary diagnosis? 3. Can you please provide clarification of the physicians recommended treatment plan, specifically: a. a description of the service to be rendered, b. the date range in which the services will be rendered, c. the number of services to be rendered, d. and the CPT codes for the services requested. 4. Can you please provide the number of visits the patient has previously made to: a. the provider? b. conservative care providers such as physical therapists or chiropractors? 5. Can you please indicate if the patient has previously undergone diagnostic testing such as MRI or EMG/NCS, and if so, the dates of these studies and their results? 6. Can you please indicate if the patient is seeing any other providers for this condition? If so, please provide their names, contact information and specialties

248 CID Management Pre-Review Script for Written Request for Medical Documentation The request was submitted without clinical information/reporting. Please forward the appropriate clinical reporting/documentation which: 1) displays the provider s request for the above procedure/service; 2) provides the patient s subjective and objective status at the time the procedure/service was requested; and 3) contains the provider s clinical rationale supporting the medical necessity of the request

249 Addendum California Claims 1. Consistent with Policy 3100, CID non-clinical administrative staff may not apply clinical judgment or interpretation. 2. Consequently, non-clinical staff are not permitted to: 2.1. Issue authorizations (certifications) 2.2. Issue denials (non-certifications) 2.3. Issue delays 2.4. Issue any request for information that is inconsistent with the scripted requests for information contained in Policy

250 Initial Clinical Review CID Management Policy No Revision: 4.2 Revision Date: 7/14/2009 Page 1 of 6 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which initial clinical review, also known as first level review, may be conducted at CID. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /1/2008 Revised Revision /21/2009 Reviewed Revision /18/2009 Revised Revision /14/2009 Revised Revision /08/2010 Reviewed Revision /14/2011 Reviewed Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects initial clinical reviewers contracted with CID. 4.0 Policy The policy of CID Management is to perform initial clinical review of all requests for authorization to determine if the request for authorization matches the CID clinical review criteria. It is further the policy of CID Management that determinations of modification, noncertification and conditional non-certification shall not be issued by initial clinical reviewers. 5.0 Definitions Definitions of terms are set forth in Policy Procedures

251 6.1 CID may utilize initial clinical review staff to perform first level review on requests for authorization submitted by providers. 6.2 Initial clinical reviewers shall have access to consultation with a: Licensed doctor of medicine or doctor of osteopathic medicine Licensed health professional in the same licensure category as the requesting physician, Health professional with the same clinical education as the requesting physician in clinical specialties where licensure is not issued. 6.3 For prospective and concurrent reviews, the initial clinical reviewers shall make the determination based solely upon information obtained by CID at the time of review determination. For retrospective reviews, the initial clinical reviewers shall make the determination based solely upon information available to the requesting physician at the time the medical care was provided. 6.4 Initial clinical review staff shall review the request for authorization and evaluate the request to determine if it complies fully with the clinical review criteria If the request for authorization complies fully with the clinical review criteria and the client contract specifies that reviews may be approved through initial clinical review, then the initial clinical review staff shall add the following items to the electronic review file and use the CID secured web-based system to electronically identify the review as complete: A specific description of the medical treatment service certified A clinical rationale which shall include: A clear and concise explanation of the reason for the decision The clinical reason regarding medical necessity A description of the medical criteria or guidelines used A written copy of the relevant portion of the criteria or guidelines used If the request for authorization does not comply fully with the clinical review criteria, or if the client contract specifies that all reviews must undergo second level review regardless of determination, then the initial

252 clinical review staff shall add the following items to the electronic review file and assign the review to a clinical peer reviewer for second level review A summary of the documents reviewed A specific description of the medical treatment services consistent with, and those inconsistent with, the clinical review criteria A clinical rationale which shall include: A clear and concise explanation of the reason for the decision The clinical reason regarding medical necessity A description of the medical criteria or guidelines used A written copy of the relevant portion of the criteria or guidelines used The initial reviewer s clinical concerns and/or rationale for forwarding the review to clinical peer review

253 Addendum Massachusetts 1.0 Initial review may only be conducted by a qualified initial clinical reviewer who has been listed within CID s UR Agent application as filed with the Office of Health Policy (OHP). New reviewers may be added to the application as needed, but should not perform any reviews until after the amended application has been filed with the OHP. In the event that a new initial clinical reviewer does complete a Massachusetts review without being added to the application, an amended application must be filed with the OHP within 30 days. 2.0 Initial clinical review may only be conducted within the physical location of the CID office(s) which have been listed on the UR Agent application filed with the OHP

254 Addendum Tennessee 1.0 Initial clinical review for Tennessee claims may only be conducted by a Registered Nurse with a valid license

255 Addendum Texas 1.0 CID will avoid contractual agreements with Texas clients requiring that reviews be sent to clinical peer review on all reviews. 2.0 Consistent with all utilization review activities at CID Management, in all instances in which an initial reviewer assigns a review to a clinical peer (second level) reviewer, there shall be no outbound notifications or documentation of any kind sent by the initial reviewer to the injured worker/employee. 3.0 In each instance in which an initial reviewer assigns a review to a clinical peer (second level) reviewer, completion of the clinical peer (second level) review shall be completed within the timelines mandated by CID Policy 3900; TIC ; and TAC Under no circumstances shall the assignment of a review to a clinical peer (second level) reviewer be deemed as a new or separate review

256 Clinical Peer Review CID Management Policy No Revision: 5.2 Revision Date: 6/17/2009 Page 1 of 7 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which clinical peer review, also known as second level review, may be conducted at CID. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /29/2008 Revised Revision /01/2008 Revised Revision /12/2009 Revised Revision /17/2009 Revised Revision /08/2010 Reviewed Revision /14/2011 Reviewed Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects clinical peer reviewers contracted with CID. 4.0 Policy The policy of CID Management is to perform clinical peer review of all requests for authorization where it has been determined that the request for authorization does not match the CID clinical review criteria or where requested by the client. It is the policy of CID Management to mandate that all determinations involving modification, non-certification or conditional non-certification be made by a clinical peer reviewer. The clinical peer reviewer shall determine if the clinical information dictates that a variance from the clinical review criteria is appropriate in which case the request for authorization shall be certified, or if the clinical information does not support a variance from the clinical review criteria in which case the request for authorization shall be non-certified. It is further the policy of CID Management that the clinical peer reviewers hold a current and valid license in the same

257 category as the requesting physician, hold a current and valid license in the discipline of the requested service, or as a doctor of medicine or doctor of osteopathic medicine. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 CID utilizes clinical peer reviewer to perform second level review on requests for authorization, appeals consideration, and re-consideration submitted by providers. 6.2 Clinical peer reviewers shall be assigned to reviews based upon a matrix developed by the medical director or clinical director such that the reviewers are qualified as determined by the medical director or clinical director to render a clinical opinion about the medical condition, procedures, and treatment under review and hold a current and valid license: In the same licensure category as the ordering provider, or In the discipline of the requested service, or As a doctor of medicine or doctor of osteopathic medicine. 6.3 Clinical peer reviewers shall review the request for authorization and evaluate the request to determine if it complies fully with the clinical review criteria. If the request for authorization has previously been reviewed by initial clinical review staff, the clinical peer reviewer shall additionally review the notes added to the review by the initial clinical review staff. 6.4 If the request for authorization falls outside the scope of clinical practice of the clinical peer reviewer, the clinical peer reviewer shall use the CID system to request the review be transferred to an alternate clinical peer reviewer. 6.5 For prospective and concurrent reviews, the clinical peer reviewers shall make the determination based solely upon information obtained by CID at the time of review determination. For retrospective reviews, the clinical peer reviewers shall make the determination based solely upon information available to the requesting physician at the time the medical care was provided. 6.6 If the request for authorization complies fully with the clinical review criteria, the peer clinical review staff shall add the following items to the electronic review file and use the CID secured web-based system to electronically identify the review as complete: A specific description of the medical treatment service certified, if any

258 6.6.2 A clinical rationale which shall include: A clear and concise explanation of the reason for the decision The clinical reason regarding medical necessity A description of the medical criteria or guidelines used A written copy of the relevant portion of the criteria or guidelines used 6.7 If the request for authorization does not comply fully with the clinical review criteria, the clinical peer reviewer shall determine if the clinical information dictates that a variance from the clinical review criteria is appropriate in which case the request for authorization shall be certified, or if the clinical information does not support a variance from the clinical review criteria in which case the request for authorization shall be non-certified. The peer clinical review staff shall then add the following items to the electronic review file and use the CID secured web-based system to electronically identify the review as complete: A specific description of the medical treatment services certified and noncertified A clinical rationale which shall include: A clear and concise explanation of the reason for the decision The clinical reason regarding medical necessity A description of the medical criteria or guidelines used A written copy of the relevant portion of the criteria or guidelines used. 6.8 For electronic review files on which initial clinical review staff have completed any of the steps listed above, the peer clinical reviewer shall review that work of the initial clinical review staff and make all necessary modifications and corrections prior to electronically marking the review as complete. 6.9 Once completed, a determination shall not be materially changed. Upon receipt of additional information, an appeal or re-consideration may be initiated however the original determination shall not be materially changed

259 Addendum State of California 1.0 Consistent with Labor Code 4610(g)(3)(B), in the case of concurrent review, medical care shall not be discontinued (non-certified, or modified such that a component of care is noncertified). until the requesting physician has been notified of the decision and a care plan has been agreed upon by the requesting physician that is appropriate for the medical needs of the injured worker. 2.0 The preferred method of such notification and subsequent agreement on a care plan is contact by telephone. All such contact and attempted contact, and attempts to agree on a care plan, must be documented by the clinical peer reviewer within the CID database. 3.0 Medical care provided during a concurrent review shall be medical treatment that is reasonably required to cure or relieve from the effects of the industrial injury. In the event that the requesting physician has not agreed to a care plan that the clinical peer reviewer believes is consistent with this standard, the clinical rationale shall provide the basis for this opinion, and shall recommend to the claims administrator that retrospective assessment of the dispute be sought as described in LC4610(g)(3)(B)

260 Addendum State of Massachusetts 1.0 Consistent with 452 CMR 6.04 (5)(c), clinical peer reviewers for utilization management functions on claims originating in the Commonwealth of Massachusetts must be from the same school (licensure) as the requesting provider. For such claims, Policy 3300 Sections and shall not be applied

261 Addendum Tennessee 1.0 Consistent with Rule , and Rule (3); a clinical reviewer on a review of a Tennessee claim must be an actively Tennessee-licensed practitioner, who is board certified, who is in good standing, who is in the same or similar general specialty as the recommending authorized treating physician

262 Addendum Texas 1.0 Consistent with Labor Code , clinical peer reviewers for utilization management functions on claims originating in Texas shall be licensed to practice in the Texas. 2.0 Clinical peer reviewers for utilization management functions on claims originating in Texas must hold a professional certification in a health care specialty appropriate to the type of health care that the injured employee is receiving. 3.0 Consistent with TIC , prior to issuance of an adverse determination, the clinical peer reviewer (physician reviewer) will make at least one attempt to contact the requesting health care provider to afford a reasonable opportunity to discuss the treatment plan and the clinical basis for the decision. If the clinical peer reviewer (physician reviewer) is unable to speak with the requesting provider, a message will be left with the reason for the call and call back information. If time permits, a second call will be made to the requesting physician by the clinical peer reviewer (physician reviewer) prior to issuance of an adverse determination. The clinical peer reviewer (physician reviewer) shall document all attempted and completed telephone calls to the requesting physician. 4.0 Consistent with TIC (b)(4), clinical peer reviewers are to use review criteria in a manner that allows deviation from the norm on a case-by-case basis. In instances where it is the reviewer s judgment that the strict application of review criteria is inappropriate to the specific patient, deviation from the review criteria should be made with explanation

263 Appeals Consideration CID Management Policy No Revision: 4.3 Revision Date: 6/8/2010 Page 1 of 13 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which appeals consideration, also known as third level review, may be conducted at CID. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /29/2008 Revised Revision /24/2009 Revised Revision /18/2009 Revised Revision /08/2010 Revised Revision /14/2011 Reviewed Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects initial clinical reviewers and clinical peer reviewers contracted with CID. 4.0 Policy The policy of CID Management is to perform appeals consideration on reviews previously completed by CID clinical reviewers, provided that the appeals consideration meet the appropriate inclusion criteria. It is further the policy of CID Management to ensure that all decisions to modify or non-certify appeals considerations are performed by board certified clinical peer reviewers who did not make the original determination to modify or non-certify the care, nor are the subordinate of such an individual. 5.0 Definitions Definitions of terms are set forth in Policy

264 6.0 Procedures 6.1 CID non-clinical administrative staff shall ensure that appeals considerations meet the following inclusion criteria. If the inclusion criteria are not met, the appeals consideration shall not be started and the requestor shall be advised to contact the claims administrator The party submitting the appeals consideration is a party authorized to do so by law. In jurisdictions without explicit designation of parties authorized to submit an appeal, submission of appeals shall be limited to the injured worker and the provider or facility providing services The appeals consideration is accompanied by medical information above and beyond that which was submitted in the initial request for authorization The appeals consideration is received within 30 calendar days of the initial determination date For concurrent reviews involving urgent care, there shall be the availability of an expedited review, and in the case of an adverse determination to the expedited appeals consideration, the further availability of a single standard appeals consideration allowed For prospective and retrospective reviews, there shall be availability of a single standard appeals consideration allowed. 6.2 Requests for appeal consideration may be initiated by parties via telephone, however shall not be started until receipt of additional medical information and specific appeal request in writing. 6.3 CID administrative staff shall forward a copy of the appeals consideration, as well as all additional medical documentation received, to the claims administrator. 6.4 CID may utilize initial clinical review staff to perform initial review on requests for appeals consideration. 6.5 Initial clinical review staff shall review the request for appeals consideration and evaluate the request to determine if it complies fully with the clinical review criteria The initial clinical review staff shall add the following items to the electronic review file and assign the review to the clinical peer reviewer specified by the CID system. The CID system shall ensure that the clinical peer reviewer chosen is: (a) a clinical peer; (b) holds an active, unrestricted license to practice medicine or a health profession; (c) are board certified in the appropriate discipline, if applicable; (d) are in the same profession and in a similar specialty as typically manages the

265 medical condition, procedure, or treatment as mutually deemed appropriate; and (e) are neither the individual who made the original noncertification, nor the subordinate of such an individual, for third level review A summary of the documents reviewed A specific description of the medical treatment services certified and non-certified A clinical rationale which shall include: A clear and concise explanation of the reason for the decision The clinical reason regarding medical necessity A description of the medical criteria or guidelines used A written copy of the relevant portion of the criteria or guidelines used The initial reviewer s clinical concerns and/or rationale for forwarding the review to clinical peer review. 6.6 Clinical peer reviewers shall review the request for appeals consideration and evaluate the request to determine if it complies fully with the clinical review criteria. If the appeals consideration has previously been reviewed by initial clinical review staff, the peer clinical reviewer shall additionally review the notes added to the review by the initial clinical review staff. 6.7 If the request for appeals consideration complies fully with the clinical review criteria, the peer clinical review staff shall add the following items to the electronic review file and use the CID secured web-based system to electronically identify the review as complete: A specific description of the medical treatment service certified A clinical rationale which shall include: A clear and concise explanation of the reason for the decision The clinical reason regarding medical necessity A description of the medical criteria or guidelines used

266 6.7.4 A written copy of the relevant portion of the criteria or guidelines used 6.8 If the request for appeals consideration does not comply fully with the clinical review criteria, the clinical peer reviewer shall determine if the clinical information dictates that a variance from the clinical review criteria is appropriate in which case the request for appeals consideration shall be certified, or if the clinical information does not support a variance from the clinical review criteria in which case the request for appeals consideration shall be non-certified. The peer clinical review staff shall then add the following items to the electronic review file and use the CID secured webbased system to electronically identify the review as complete: A specific description of the medical treatment services certified and noncertified A clinical rationale which shall include: A clear and concise explanation of the reason for the decision The clinical reason regarding medical necessity A description of the medical criteria or guidelines used A written copy of the relevant portion of the criteria or guidelines used. 6.9 For electronic review files on which initial clinical review staff have completed any of the steps listed above, the peer clinical reviewer shall review that work of the initial clinical review staff and make all necessary modifications and corrections prior to electronically marking the review as complete

267 Addendum State of California 1.0 Background of addendum: Consistent with Jesus Cervantes v El Aguila Food Products, Inc. et al (Cervantes), as a matter of law the following procedural pathway applies to requests for spinal surgery, as defined in 8CCR9788.1: A) If the claims administrator authorizes the request for spinal surgery, then the spinal surgery request is authorized. B) If the claims administrator send the request for utilization review: i) If the reviewer recommends authorization, then the spinal surgery request is authorized. ii) If the utilization review process is not completed within 10 calendar days of the receipt of request for authorization of spinal surgery, then the spinal surgery request is authorized. iii) If the reviewer recommends that the spinal surgery request should not be authorized, then the claims administrator must file a formal request with the Division of Workers Compensation to arrange a face-to-face surgical second opinion evaluation as described in LC4062(b). If the claims administrator must file this request completely and correctly; after denial through utilization review; and within 10 calendar days of the receipt of the request for spinal surgery. If any of these conditions are not met, then the spinal surgery request is authorized. iv) If the injured worker or requesting physician seek a voluntary appeal to utilization review, and if the appellate reviewer recommends authorization of the surgery, then the spinal surgery request is authorized, and the 4062(b) evaluation does not need to proceed. If an appellate reviewer recommends that the request for spinal surgery should be denied, then the previously requested 4062(b) evaluation proceeds. C) If the face-to-face surgical second opinion evaluation is completed, and the second opinion evaluator recommends that the surgery should be authorized, then the spinal surgery request is authorized. If the second opinion surgical evaluator recommends denial of the request for spinal surgery, then the claims administrator must file a request for adjudication before the Workers Compensation Appeals Board. If the claims administrator fails to make a timely filing for adjudication, then the spinal surgery request is authorized.. 2.0) In consideration of the procedural mandates of California outlined above; and that a face-toface evaluation by a qualified and independent spinal surgeon provides a stronger safeguard of the injured worker than a documentation-based appeal review; and that the only potential significant benefit of such an appeal is process cost savings for the claims administrator: The claims administrator may elect to deny access to an appeal review following an adverse determination of a request for spinal surgery, but only when all of the following conditions are met: A) The claim is under the jurisdiction of the State of California; B) The request for authorization for spinal surgery satisfies the definition of request for authorization found in 8CCR9792.6(o) and clarified in the Cervantes decision [PR

268 report; Form 5021; or narrative report bearing the words Request for authorization of spinal surgery ]; and C) The adverse determination applies only to services defined as spinal surgery within 8CCR (e.g., original utilization review was for spinal surgery only, or all other requests were certified/authorized by the clinical reviewer) and/or services associated only with the surgery request (e.g., peri-operative goods and services, post-operative therapy)

269 Addendum State of Massachusetts 1.0 Consistent with clarification from Jane Bennett of the Office of Health Policy, appeal review of adverse determinations of Massachusetts claims must be initiated upon request in any form, written or oral, from the patient or provider, even if that request for appeal contains no additional information of any kind. 2.0 Consistent with 452CMR6.04(5)(d), requests for appeal must be made within 30 days of the original adverse determination. 3.0 Consistent with 452CMR6.04(5)(d)(1), appeals of prospective or concurrent requests must be completed within 2 business days of initiation of the appeal, unless the ordering provider agrees to a different time period. Such agreements are to be documented as a review activity by CID staff. 4.0 Consistent with 452CMR6.04(5)(d)(2), appeals of retrospective requests must be completed within 20 days from the date the appeal is filed

270 Addendum State of Tennessee 1.0 Consistent with Rule , appeals are not to be conducted on Tennessee claims. Appeals are to be completed by the Division of Workers Compensation. 2.0 From time to time, the Division may send correspondence requiring a second review of services previously subject to an adverse determination. In such cases a new review is to be initiated, as if there were a new request for authorization; and not as an appeal

271 Addendum State of Texas 1.0 In the event of an adverse determination, an appeal may be requested orally or in writing by an enrollee (injured worker); a person acting on the enrollee s behalf; or the enrollee s physician or other health care provider. 2.0 Upon oral or written request for an appeal by an authorized party, written acknowledgement of the request for appeal is to be sent to the party requesting the appeal within 5 working days from the date that CID receives the appeal. Such written notice must include the date of receipt of request for appeal; a list of the procedures required by TIC 4201 Subchapter H; and a list of any documents that the appealing party must submit for review. The acknowledgement letter shall also be accompanied by a one-page appeal form. 3.0 The clinical peer reviewer making the decision on the appeal must: 3.1 Be a physician, as defined under Texas statute (MD or DO) [TIC (a)]. 3.2 Hold a professional certification in a health care specialty appropriate to the type of health care that the injured employee is receiving. [Labor Code (b)] 3.3 Be a provider other than the provider who made the original adverse determination [28 TAC (a)(1)] 4.0 Within 10 working days after the date the appeal is denied, the health care provider may request a particular type of specialty provider review the case. This request must be in writing and include good cause for the request. If there is good cause, a health care provider who is of the same or similar specialty as the provider who typically manages the medical or dental condition, procedure or treatment under consideration for review will review the decision denying the appeal. This specialty review must be completed within 15 working days of the date the provider s request for specialty review was received. 5.0 Transmission of written determination letters following resolution of an appeal are to be sent in accordance with CID policy Recipients of such notice must include the patient or person acting on the patient s behalf; and the patient s physician or other health care provider. 5.2 The determination letter must include: The outcome of the reconsideration; A statement of the specific medical or clinical reasons for the recommendation; The professional specialty of the reviewing physician and any consulting providers and the state(s) in which the provider is licensed; and Notice of the requesting party s right to seek review of the denial by an independent review organization (IRO) and the procedures for obtaining that review. 6.0 An expedited appeal shall be afforded in instances of adverse determinations involving requests for emergency care, urgent care or post-stabilization treatment. Following an adverse determination, the following process is to be observed regarding the Texas Independent Review Organization (IRO) process

272 7.0 In the event of an adverse determination, the injured worker, the injured worker s representative and the requesting provider will be notified in writing of the availability of and directions for requesting an independent review process 7.1 after the reconsideration process is completed and the adverse determination is upheld 7.2 after the initial adverse determination available only if the injured worker s condition is life threatening (bypasses reconsideration process) 8.0 A request for independent review will be accepted no later than the 45th calendar day after the receipt of the denial of reconsideration for non-networks, and no later than the 45 th day after the date of denial of a reconsideration for networks. This request may be received from the injured worker, the injured worker s representative or the provider for a preauthorization, concurrent or retrospective utilization review. 8.1 A request for independent review must be filed in the form and manner prescribed by the Department. The Department's IRO request form may be obtained from: the Department's Internet website at or the Health and Workers' Compensation Network Certification and Quality Assurance Division, Mail Code 103-6A, Texas Department of Insurance, P.O. Box , Austin, Texas CID shall submit an IRO request to the Texas Department of Insurance via the online request form one working day of receipt of the request for independent review. Once the online review is submitted, the confirmation of receipt of a request for review by an IRO will be printed and faxed to the Texas Department of Insurance at with the copies of: 9.1 UR determination letters 9.2 Injured worker IRO request form 9.3 Company request for IRO form-printed with confirmation page 10.0 The Texas Department of Insurance will randomly assign an independent review organization within 1 working day of the receipt of the online request and will notify CID, the IRO, the injured worker, the injured worker s representative and the requesting provider No later than the 3rd working day after CID s receipt of the request for independent review, CID will provide to the assigned IRO via fax a copy of: 11.1 the forms prescribed by the Department for requesting IRO review; 11.2 any medical records we have that are relevant to the review 11.3 any documents used in making the determinations, including guidelines, policies, protocols and criteria 11.4 written notification of the initial adverse determination and written notification of the reconsideration upheld (UR determination letters) 11.5 any documentation submitted to CID in support of the appeal 11.6 a list of names, addresses and phone numbers of each physician or health care provider who has provided care to the injured worker and who may have medical records relevant to the appeal any other information required by the Department related to a request from a carrier for the assignment of an IRO

273 12.0 In the event that the IRO shall request additional information from CID, CID shall deliver all such requested information in its possession as directed by the IRO. CID may not seek reimbursement for copies of records sent to the IRO CID will comply with the IRO s determination CID s client will be copied on the online IRO request submission and agrees to issue payment for the IRO. IRO fees will be paid in the same amounts as the IRO fees set by Department rules. In addition to the specialty classifications established as tier two fees in Department rules, independent review by a doctor of chiropractic shall be paid the tier two fee. IRO fees shall be paid as follows: 14.1 In network disputes, a preauthorization, concurrent, or retrospective medical necessity dispute for health care provided by a network, the carrier must remit payment to the assigned IRO within 15 days after receipt of an invoice from the IRO; 14.2 In non-network disputes, IRO fees for disputes regarding non-network health care must be paid as follows: in a preauthorization or concurrent review medical necessity dispute or retrospective medical necessity dispute resolution when reimbursement was denied for health care paid by the employee, the carrier shall remit payment to the assigned IRO within 15 days after receipt of an invoice from the IRO in a retrospective medical necessity dispute, the requestor must remit payment to the assigned IRO within 15 days after receipt of an invoice from the IRO if the IRO fee has not been received within 15 days of the requestor's receipt of the invoice, the IRO shall notify the Department and the Department shall dismiss the dispute with prejudice after an IRO decision is rendered, the IRO fee must be paid or refunded by the nonprevailing party as determined by the IRO in its decision Designated doctor examinations requested by an IRO shall be paid by the carrier in accordance with the medical fee guidelines under the Labor Code and related rules Failure to pay or refund the IRO fee may result in enforcement action as authorized by statute and rules and removal from the Division's Approved Doctor List For health care not provided by a network, the non-prevailing party to a retrospective medical necessity dispute must pay or refund the IRO fee to the prevailing party upon receipt of the IRO decision, but not later than 15 days regardless of whether an appeal of the IRO decision has been or will be filed The IRO fees may include an amended notification of decision if the Department determines the notification to be incomplete. The amended notification of decision shall be filed with the Department no later than five working days from the IRO's receipt of such notice from the Department. The amended notification of decision does not alter the deadlines for appeal

274 14.7 If a requestor withdraws the request for an IRO decision after the IRO has been assigned by the Department but before the IRO sends the case to an IRO reviewer, the requestor shall pay the IRO a withdrawal fee of $150 within 30 days of the withdrawal. If a requestor withdraws the request for an IRO decision after the case is sent to a reviewer, the requestor shall pay the IRO the full IRO review fee within 30 days of the withdrawal In addition to Department enforcement action, the Division may assess an administrative fee in accordance with Labor Code and 28 TAC This section shall not be deemed to require an employee to pay for any part of a review. If application of a provision of this section would require an employee to pay for part of the cost of a review, that cost shall instead be paid by the carrier If an IRO decision determines that medical necessity exists for health care that the carrier denied and the carrier utilized a peer review report on which to base its denial, the peer review report shall not be used for subsequent medical necessity denials of the same health care services subsequently reviewed for that compensable injury

275 Addendum State of Utah 1.0 Appeals of reviews on Utah claims are to be conducted in accordance with R (5)(B)(2). Specifically; 2.0 A physician, who has been denied authorization of payment for treatment, or has received no response within five business days from the request for authorization for payment at Level I review, may request a physician's review by sending the completed portion of the Commission Form 223 to the payor. 3.0 The appeal review must be completed within 5 business days of the receipt of request for an appeal. 4.0 CID non-clinical staff must initiate such appeals as containing a request for a peer-to-peer consultation. Before the clinical peer reviewer may issue an adverse determinantion, a reasonable effort must have made to contact the requesting treating physician to discuss the differing aspects of the case. A reasonable effort requires 2 attempted telephone calls and a fax; or three telephone calls. 5.0 Any adverse determination on such an appeal must be transmitted with the Commission s Form Any adverse determination and accompanying Form 223 must be transmitted to the physician; claimant (patient); and the Commission

276 Reconsiderations of Determinations at the Request of Claims Administrators CID Management Policy No Revision: 1.0 Revision Date: 5/13/2009 Page 1 of 5 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which reconsiderations of determinations, including certifications, may be conducted at CID at the request of the claims administrator. 2.0 Revision History Revision /13/2009 New Policy/Initial Implementation Revision /08/2010 Reviewed Revision /14/2011 Reviewed Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects initial clinical reviewers and clinical peer reviewers contracted with CID. 4.0 Policy The policy of CID Management is to perform reconsideration on reviews previously completed by CID initial and/or clinical reviewers, at the request of the claims administrator, provided that the reconsideration request meets the appropriate inclusion criteria. It is further the policy of CID Management to ensure that reconsiderations are performed by the reviewer who issued the original determination, if available; that any adverse determinations (conditional non-certification, non-certification or modification) arising from such reconsideration must be issued by a clinical peer reviewer; and that in the event of reversal or alteration of a certification, there shall be made available to the patient or provider the opportunity for a standard appeal. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 CID non-clinical administrative staff shall ensure that reconsiderations at the request of the claims administrator meet the following inclusion criteria. If the inclusion

277 criteria are not met, the reconsideration shall not be started and the claims administrator shall be so advised The party submitting the request for reconsideration is a party authorized to do so by the claims administrator The determination for which reconsideration is being requested did not arise from an appeal The reconsideration request is provided in writing; includes a written indication of the basis for disagreement with the original determination; and the request is based on at least one of the following assertions: That the reviewer did not have access to crucial medical information; That the reviewer failed to consider substantive information already available; That the reviewer made significant factual errors in interpreting the available medical documents; and/or That the reviewer substantively misapplied clinical review criteria (e.g., evidence-based guidelines) In all instances in which a reconsideration of a certification is requested, the request must be accompanied by medical information above and beyond that which was submitted in the initial request for authorization The written request for reconsideration is received within 14 calendar days of the initial determination date. 6.2 Requests for reconsideration may be initiated by an authorized party via telephone, however shall not be started until receipt of additional written materials as described above in and CID administrative staff shall forward a copy of the request for reconsideration, as well as all additional medical documentation received, to the provider of medical goods or services and to the injured worker. 6.4 In the event that client-requested reconsideration is made regarding concurrent inpatient services not yet provided, the client-requested reconsideration must be completed and determination notice sent prior to the dates of service for the request(s) under review. 6.5 CID may utilize initial clinical review staff to perform initial review on requests for reconsideration

278 6.6 Initial clinical review staff shall review the request for reconsideration and evaluate the request to determine if it complies fully with the clinical review criteria The initial clinical review staff shall add the following items to the electronic review file and assign the review to the clinical peer reviewer specified by the CID system. The CID system shall ensure that the clinical peer reviewer chosen is: (a) a clinical peer; (b) holds an active, unrestricted license to practice medicine or a health profession; (c) are board certified in the appropriate discipline, if applicable; (d) are in the same profession and in a similar specialty as typically manages the medical condition, procedure, or treatment as mutually deemed appropriate; and (e) are the individual who made the original determination, if available A summary of the documents reviewed A specific description of the medical treatment services certified and non-certified A clinical rationale which shall include: A clear and concise explanation of the reason for the original decision A clear and concise statement of the reasoning for the reconsideration request The clinical reason regarding medical necessity A description of the medical criteria or guidelines used A written copy of the relevant portion of the criteria or guidelines used The initial reviewer s clinical concerns and/or rationale for forwarding the review to clinical peer review. 6.7 Clinical peer reviewers shall review the request for reconsideration and evaluate the request to determine if it complies fully with the clinical review criteria. If the reconsideration has previously been reviewed by initial clinical review staff, the peer clinical reviewer shall additionally review the notes added to the review by the initial clinical review staff. 6.8 If the request for reconsideration complies fully with the clinical review criteria, the peer clinical review staff shall add the following items to the electronic review file

279 and use the CID secured web-based system to electronically identify the review as complete: A specific description of the medical treatment service certified A clinical rationale which shall include: A clear and concise explanation of the reason for the decision The clinical reason regarding medical necessity A description of the medical criteria or guidelines used A written copy of the relevant portion of the criteria or guidelines used 6.9 If the request for reconsideration does not comply fully with the clinical review criteria, the clinical peer reviewer shall determine if the clinical information dictates that a variance from the clinical review criteria is appropriate in which case the request for reconsideration shall be certified, or if the clinical information does not support a variance from the clinical review criteria in which case the request for appeals consideration shall be non-certified. The peer clinical review staff shall then add the following items to the electronic review file and use the CID secured webbased system to electronically identify the review as complete: A specific description of the medical treatment services certified and noncertified A clinical rationale which shall include: A clear and concise explanation of the reason for the decision The clinical reason regarding medical necessity A description of the medical criteria or guidelines used A written copy of the relevant portion of the criteria or guidelines used For electronic review files on which initial clinical review staff have completed any of the steps listed above, the peer clinical reviewer shall review that work of the initial clinical review staff and make all necessary modifications and corrections prior to electronically marking the review as complete In no instance shall conducting a reconsideration review be considered as a substitute for the appeals process afforded to the injured worker/provider under Policy

280 6.12 In the event that a reconsideration of previously certified medical goods or services results in a reversal of any or all of the certification, the injured worker/provider must be afforded the opportunity for a standard appeal, and must be properly notified of that opportunity and appropriate process

281 Re-Considerations CID Management Policy No Revision: 3.0 Revision Date: 1/29/2008 Page 1 of 5 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which re-considerations may be conducted at CID. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /29/2008 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /14/2011 Reviewed Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects initial clinical reviewers and clinical peer reviewers contracted with CID. 4.0 Policy The policy of CID Management is to perform re-considerations on reviews previously noncertified by CID clinical peer reviewers due to a lack of information, provided that the reconsideration meets the appropriate inclusion criteria 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 CID non-clinical administrative staff shall ensure that re-considerations meet the following inclusion criteria. If the inclusion criteria are not met, the appeals consideration shall not be started and the requestor shall be advised to contact the claims administrator

282 6.1.1 The party submitting the re-consideration is a party authorized to do so by law The re-consideration is accompanied by medical information above and beyond that which was submitted in the initial request for authorization The re-consideration is received within 45 calendar days of the initial determination date. 6.2 CID administrative staff shall forward a copy of the re-consideration, as well as all additional medical documentation received, to the claims administrator. 6.3 CID may utilize initial clinical review staff to perform initial review on requests for re-consideration. 6.4 Initial clinical review staff shall review the request for re-consideration and evaluate the request to determine if it complies fully with the clinical review criteria If the request for re-consideration complies fully with the clinical review criteria, the initial clinical review staff shall add the following items to the electronic review file and use the CID secured web-based system to electronically identify the review as complete: A specific description of the medical treatment service certified A clinical rationale which shall include: A clear and concise explanation of the reason for the decision The clinical reason regarding medical necessity A description of the medical criteria or guidelines used A written copy of the relevant portion of the criteria or guidelines used If the request for re-consideration does not comply fully with the clinical review criteria, the initial clinical review staff shall add the following items to the electronic review file and assign the review to the clinical peer reviewer who reviewed the original request, if available. If the clinical peer reviewer who reviewed the original request is not available, the review shall be assigned to a clinical peer reviewer competent to evaluate the services requested A summary of the documents reviewed

283 A specific description of the medical treatment services certified and non-certified A clinical rationale which shall include: A clear and concise explanation of the reason for the decision The clinical reason regarding medical necessity A description of the medical criteria or guidelines used A written copy of the relevant portion of the criteria or guidelines used The initial reviewer s clinical concerns and/or rationale for forwarding the review to clinical peer review. 6.5 Clinical peer reviewers shall review the request for re-consideration and evaluate the request to determine if it complies fully with the clinical review criteria. If the reconsideration has previously been reviewed by initial clinical review staff, the peer clinical reviewer shall additionally review the notes added to the review by the initial clinical review staff. 6.6 If the request for re-consideration complies fully with the clinical review criteria, the peer clinical review staff shall add the following items to the electronic review file and use the CID secured web-based system to electronically identify the review as complete: A specific description of the medical treatment service certified A clinical rationale which shall include: A clear and concise explanation of the reason for the decision The clinical reason regarding medical necessity A description of the medical criteria or guidelines used A written copy of the relevant portion of the criteria or guidelines used 6.7 If the request for re-consideration does not comply fully with the clinical review criteria, the clinical peer reviewer shall determine if the clinical information dictates that a variance from the clinical review criteria is appropriate, in which case the

284 request for re-consideration shall be certified, or if the clinical information does not support a variance from the clinical review criteria in which case the request for reconsideration shall be non-certified. The peer clinical review staff shall then add the following items to the electronic review file and use the CID secured web-based system to electronically identify the review as complete: A specific description of the medical treatment services certified and noncertified A clinical rationale which shall include: A clear and concise explanation of the reason for the decision The clinical reason regarding medical necessity A description of the medical criteria or guidelines used A written copy of the relevant portion of the criteria or guidelines used. 6.8 For electronic review files on which initial clinical review staff have completed any of the steps listed above, the peer clinical reviewer shall review that work of the initial clinical review staff and make all necessary modifications and corrections prior to electronically marking the review as complete

285 Addendum State of Tennessee 1.0 Consistent with Rule (5)(b), reconsiderations of denial based on insufficient information are not to be conducted by CID on Tennessee claims. Such reviews are to be completed by the Division of Workers Compensation. 2.0 From time to time, the Division may send correspondence requiring a second review of services previously subject to an adverse determination due to insufficient information. In such cases a new review is to be initiated, as if there were a new request for authorization; and not as a reconsideration review

286 Telephonic Peer To Peer Consultation CID Management Policy No Revision: 3.0 Revision Date: 6/5/07 Page 1 of 2 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which telephonic peer to peer consultations may occur in the performance of utilization management operations. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /14/2011 Reviewed Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects clinical peer reviewers contracted with CID. 4.0 Policy The policy of CID Management is to perform telephonic peer to peer consultations during utilization management operations when specifically requested by the client or by the requesting physician. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 If requested by a client or requesting physician, CID clinical peer reviewers may conduct telephonic peer to peer consultations prior to developing a determination for requests for authorization, appeals consideration, or re-considerations

287 6.2 If a telephonic peer to peer consultation is requested by a client or a requesting physician, CID clinical peer reviewers shall attempt a phone call to the requesting physician s office during regular business hours. This process shall be repeated up to 3 times, at a frequency of one call per day, as permitted by the regulatory timeframes associated with the review. The clinical peer reviewer shall leave messages on each attempt indicating their return number and the times that they can be reached. 6.3 If a telephonic peer to peer consultation is requested by a client or a requesting physician, and if the requesting physician has not responded to the clinical peer reviewer s attempts to contact them by telephone, then following the third attempt, or a lesser number of attempts if dictated by regulatory timeframes associated with the review, the clinical peer reviewer shall complete utilization management determination without speaking to the requesting physician. 6.4 If a telephonic peer to peer consultation is requested by a client or a requesting physician, and if the clinical peer reviewer speaks with the requesting physician, the clinical peer reviewer shall document the call in the activities section of the electronic review file and shall reference the telephone call in the clinical rationale section of the review determination. 6.5 If a telephonic peer to peer consultation is requested by a client or a requesting physician, and if the clinical peer reviewer is not available at a time that the requesting physician is available, the Clinical Director or Director of Production shall assign another clinical peer reviewer who is qualified to review the requested treatment, to make the telephone call within 1 business day at a time when the requesting physician is available

288 Requests for Information and Notifications of Extension of Review Due Date CID Management Policy No Revision: 3.2 Revision Date: 5/14/2012 Page 1 of 5 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines for sending notifications of extension of review due date to the requesting physician. It establishes the situations and reasons for which notifications of extension of review due date may be sent. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /14/2011 Reviewed Revision /25/2012 Revised Revision /14/2012 Revised 3.0 Persons Affected This policy affects all CID employees and contractors performing utilization management operations. 4.0 Policy The policy of CID Management is to complete reviews only upon receipt of all reasonably necessary medical information. If the initial clinical reviewer or clinical peer reviewer determines that they are not in possession of all reasonably necessary medical information required to complete the review, they shall notify the stakeholders of the information they require and that the review determination due date will be extended until said information is submitted, or until deadline for providing information is reached. Further, it is the policy of CID Management to ensure that reviews are completed by clinical staff members competent to evaluate the medical services requested. In the event that an expert reviewer is required, CID shall notify the stakeholders that an expert reviewer is being assigned to the review and that the determination due date will be extended pending receipt of the expert reviewer s determination

289 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 During the utilization management process, non-clinical administrative staff, initial clinical review staff or clinical peer reviewers may determine that the review may not be completed in the allowed timeframes and that a notification of extension of review due date must be sent. 6.2 The notification of extension of review due date shall be sent within the time limits for such process as established by URAC or by the jurisdiction of the claim; whichever is sooner. 6.3 The two situations in which a notification of extension of review due date may be sent: The request for authorization is not accompanied by medical documentation of any kind. Non-clinical staff or reviewers may utilize the scripted write request for information found in Policy The necessary medical information reasonably needed to make a determination is not present and needs to be requested from the provider by either the initial clinical review staff or the clinical peer reviewer. 6.4 The notification of extension of review due date shall contain the anticipated date on which a decision will be rendered and any language required by applicable law or regulations. 6.5 If a notification of extension of review due date is sent to the provider requesting additional information that the initial clinical review staff or clinical peer reviewer deems is reasonably necessary to make the determination, then: The information requested shall be limited to information reasonably necessary to certify the admission, procedure or treatment, length of stay, or frequency or duration of services The notification of extension of review due date may be delivered to any party specified by the client including, but not limited to: Claims administrator Nurse case manager

290 6.5.5 Attending physician Requesting physician Provider(s) of services or goods other than the attending or requesting physicians Patient Patient s legal counsel Client s legal counsel If the client indicates that they do not want CID to distribute the notification of extension of review due date to a party that is required by law to receive said notifications of extension of review due date, the client shall assume the responsibility of distributing these notifications of extension of review due date themselves Notifications of extension of review due date may be delivered to the appropriate parties via any method specified by the client including, but not limited to secured electronic means, fax, US mail, and courier service If the client indicates that they do not want CID to distribute the notification of extension of review due date to a party via a method specified by law, the client shall assume the responsibility of distributing these notifications of extension of review due date themselves The requested information shall be accepted from any reasonably reliable source If the requested information is received within 2 business days, the nonclinical administrative staff shall upload the requested information to the electronic review file and shall assign the review to the appropriate initial clinical review staff or clinical peer reviewer for completion If the requested information is not received within 2 business days, the non-clinical administrative staff may send an additional copy of the request for information to the requesting physician Steps and may continue until the information is received or until the day prior to the regulatory due date If the requested information is not received by the day prior to the regulatory due date,

291 For states in which conditional denials may be rendered, the CID system shall add the following language to the review: In regard to the request for (request), CID faxed the provider requesting additional information. As of this date, the provider has not submitted the requested data. To comply with utilization review timeframes it is recommended that the request be conditionally denied. The request will be reconsidered upon receipt of the information requested For states in which conditional denials may not be rendered, the CID system shall add the following language to the review: In regard to the request for (request), CID faxed the provider requesting additional information. As of this date, the provider has not submitted the requested data. To comply with utilization review timeframes it is recommended that the request be denied due to lack of medical evidence Assign the review to a clinical peer reviewer for completion 6.6 If a notification of extension of review due date is sent to the provider informing them that a specialized consultation and review of medical information by an expert reviewer is required in order to make an appropriate determination then: The notification of extension of review due date shall include the specialty of the expert reviewer consulted The notification of extension of review due date may be delivered to any party specified by the client including, but not limited to Claims administrator Nurse case manager Attending physician Requesting physician Provider(s) of services or goods other than the attending or requesting physicians Patient Patient s legal counsel

292 Client s legal counsel If the client indicates that they do not want CID to distribute the notification of extension of review due date to a party that is required law to receive said notifications of extension of review due date, the client shall assume the responsibility of distributing these notifications of extension of review due date themselves Notifications of extension of review due date may be delivered to the appropriate parties via any method specified by the client including, but not limited to secured electronic means, fax, US mail, and courier service If the client indicates that they do not want CID to distribute the notification of extension of review due date to a party via a method specified by law, the client shall assume the responsibility of distributing these notifications of extension of review due date themselves The review shall be forwarded to the expert reviewer immediately Once a determination is received from the expert reviewer, it shall be uploaded to the system within the same business day and shall be immediately distributed to the stakeholders as per client contract

293 Reimbursement For Duplication Of Records CID Management Policy No Revision: 3.0 Revision Date: 6/5/07 Page 1 of 2 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which parties shall be reimbursed in the event that they are required to submit duplicate reports as a result of the utilization management process. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /14/2011 Reviewed Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects all clients and all stakeholders on reviews completed by CID Management. 4.0 Policy The policy of CID Management is to avoid requiring stakeholders to submit duplicate copies of records as a result of the utilization management process. It is further the policy of CID management to inform all clients and employers, with whom CID is contracted for utilization management services, that it is their responsibility to reimburse providers for duplicate copies of records as required by the labor code and regulations. 5.0 Definitions Definitions of terms are set forth in Policy

294 6.0 Procedures 6.1 Upon initiation of a contract with a client, CID shall train the client s administration, supervisory staff and general staff on the CID utilization review process. 6.2 As a component of the initial training of the client s administration, supervisory staff and general staff, CID shall inform all parties to verify their responsibility to reimburse providers for duplicate records in compliance with labor code and regulations. 6.3 CID shall convey to the client s administration, supervisory staff and general staff that they should forward all relevant medical records for review to avoid requiring the provider to submit duplicate records. 6.4 If providers contact CID to request payment for duplication of records via any means including, but not limited to: telephone, fax, mail, , or web, CID shall inform them to contact the claims administrator. 6.5 To avoid requesting duplicate copies of records, prior to requesting additional information from the provider, CID initial clinical reviewers and clinical peer reviewers shall review all documents attached to prior reviews on a claimant s claim. Only in the event that CID does not have a copy of the document, shall the initial clinical reviewer or clinical peer reviewer contact the provider for a copy

295 Utilization Management Correspondence CID Management Policy No Revision: 4.2 Revision Date: 3/12/2009 Page 1 of 10 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines for correspondence generation as a component of the utilization management operation. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /15/2007 Revised Revision /05/2007 Revised Revision /01/2008 Revised Revision /12/2009 Revised Revision /08/2010 Reviewed Revision /14/2011 Reviewed Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects all CID employees and contractors who participate in the utilization management operations. 4.0 Policy The policy of CID Management is to provide correspondences at each step of the utilization management process to inform all parties of the status of the review. It is further the policy of CID Management to allow the clients to customize which correspondences are sent, and to which stakeholders they are sent. 5.0 Definitions Definitions of terms are set forth in Policy Procedures

296 6.1 During the performance of utilization management, the following documents may be created by the CID system: Request for utilization review received. This correspondence is generated when the request for authorization, appeals consideration, or reconsideration is first uploaded into the CID system Notification of extension of review due date additional information required. This correspondence is generated when it is determined that additional clinical information is required in order to make an appropriate determination Notification of extension of review due date additional tests/procedures required. This correspondence is generated when it is determined that additional clinical tests and/or procedures must be performed, and their results forwarded to CID, in order to make an appropriate determination Notification of extension of review due date expert reviewer. This correspondence is generated when it is determined that an expert clinical reviewer is needed to review the request Notification the provider submitted additional information. This correspondence is generated when the provider submits the additional information, or the additional test and/or procedures findings, requested following a notification of extension of review due date Determination letter Certified. This correspondence is generated when it is determined that the request for authorization, appeals consideration, or re-consideration is being certified Determination letter Modified. This correspondence is generated when it is determined that the request for authorization, appeals consideration, or re-consideration is being partially certified Determination letter Non-certified. This correspondence is generated when it is determined that the request for authorization, appeals consideration, or re-consideration is being non-certified Determination letter Conditionally Non-certified. This correspondence is generated when there has been a request for additional information, or the clinical findings from additional tests and/or procedures, and the information has not been received by the regulatory due date

297 Review placed on hold by CID. This correspondence generates when CID places a review on hold pending additional information from the claims administrator that is required to complete the review Review placed on hold by client. This correspondence generates when the client places a review on hold Review off of hold, back in progress. This correspondence generates when a review is taken off of CID enforced hold or client enforced hold, and is assigned to either an initial clinical reviewer or a clinical peer reviewer Review withdrawn by CID. This correspondence generates when CID withdraws a review that it began in error Review withdrawn by client. This correspondence generates when the client requests that CID cease action on a review and withdraws it from review. 6.2 All correspondences shall include a reference number to the specific review in question. 6.3 All determination correspondences shall contain the following elements: The date on which a decision is made A description of the specific course of proposed medical treatment for which authorization was requested A specific description of the medical treatment services certified, if any. If for a hospital stay, this shall include the number of days or units of service certified, if any, the next anticipated review point, if any, the new total number of days or services approved, if any, and the date of admission or onset of services, if any For all reviews with an adverse determination, the determination correspondence shall also include: A clinical rationale which shall include: A clear and concise explanation of the reason for the decision The principle reason regarding medical necessity A description of the medical criteria or guidelines used

298 A written copy of the relevant portion of the criteria or guidelines used Details about the claims administrator s internal utilization review appeals process, if any, and a clear statement that the appeal process is on a voluntary basis The name of the initial clinical review staff and/or clinical peer reviewer that made the determination The specialty of the reviewer, if any The CID contact telephone number The CID hours of availability 6.4 The correspondences shall be delivered to the following parties, as identified on the review, unless not required by law or specifically excluded by the client contract: Claims administrator Nurse case manager Attending physician Requesting physician Facility rendering service Secondary physicians Provider(s) of services or goods other than the attending or requesting physicians Patient Patient s legal counsel Client s legal counsel 6.5 If the client indicates that they do not want CID to distribute the correspondences to a party that is required by law to receive said correspondences, the client shall assume the responsibility of distributing these correspondences themselves. 6.6 Correspondences shall be delivered to the parties via the following specified method, unless the client contract specifies otherwise:

299 6.6.1 Claims administrator by within 24 hours of decision Nurse case manager by within 24 hours of decision Attending physician by fax within 24 hours of decision Requesting physician by fax within 24 hours of decision Facility rendering service by fax within 24 hours of decision Secondary physicians by fax within 24 hours of decision Provider(s) of services or goods other than the attending or requesting physicians by fax within 24 hours of decision Patient by mail, to be mailed within 24 hours of decision for concurrent review and within 1 business day of decision for all other reviews Patient s legal counsel by mail, to be mailed within 24 hours of decision for concurrent review and within 1 business day of decision for all other reviews Client s legal counsel by mail, to be mailed within 1 business day of decision 6.7 If the client indicates that they do not want CID to distribute correspondences to a party via a method specified by law, the client shall assume the responsibility of distributing these correspondences themselves. 6.8 Unless specifically barred by contract with the client, upon request by any authorized party, CID shall re-issue a copy of the original communication and forward by fax or . If CID is barred from doing so by contract with client, the party shall be advised to contact the claims administrator for a copy of the communication

300 Addendum California Claims 1.0 For California claims, the following elements will be added to adverse determination letters: 1.1 A clear statement that any dispute shall be resolved in accordance with the provisions of Labor Code section 4062, and that an objection to the utilization review decision must be communicated by the injured worker or the injured worker s attorney on behalf of the injured worker to the claims administrator in writing within 20 days of receipt of the decision. It shall further state that the 20-day time limit may be extended for good cause or by mutual agreement of the parties. The letter shall further state that the injured worker may file an Application for Adjudication of Claim and Request for Expedited Hearing, DWC Form 4, showing a bona fide dispute as to entitlement to medical treatment in accordance with sections 10136(b)(1), 10400, and CID understands that DWC Form 4 has been replaced by different forms, but mention of DWC Form 4 is required under regulation, and will continue until such time as the regulations are amended. 1.2 The following mandatory language: "If you want further information, you may contact the local state Information and Assistance office by calling [enter district I & A office telephone number closest to the injured worker] or you may receive recorded information by calling The following mandatory language You may also consult an attorney of your choice. Should you decide to be represented by an attorney, you may or may not receive a larger award, but, unless you are determined to be ineligible for an award, the attorney's fee will be deducted from any award you might receive for disability benefits. The decision to be represented by an attorney is yours to make, but it is voluntary and may not be necessary for you to receive your benefits." 1.4 The following mandatory language "If you disagree with the utilization review decision and wish to dispute it, you must send written notice of your objection to the claims administrator within 20 days of receipt of the utilization review decision in accordance with Labor Code section You must meet this deadline even if you are participating in the claims administrator s internal utilization review appeals process. 2.0 On all correspondences to non-physician providers of goods or service, the clinical rationales and guidelines shall be removed consistent with CA Labor Code and Regulations

301 Addendum Massachusetts Claims 1.0 For Massachusetts claims, the Request for utilization review received correspondence, also known as the Introductory Letter, shall contain the following: 1.1 An introductory paragraph reflecting the regulatory statute. 1.2 CID s toll free telephone number. 1.3 Information about the ID card sent by the insurer and who to contact (and telephone number) if the card has not been received. 1.4 Information regarding emergency care. 1.5 Statement that the UR agent shall allow 24 hours after emergency admission, service, or procedure for an injured employee or their representative to request approval of such service. 1.6 A paragraph outlining the CID complaint process that addresses complaints against the actions or in-actions of CID. 2.0 For Massachusetts claims, the determination letters shall additionally contain the following: 2.1 After exhaustion of the process set forth in 452 CMR 6.04(4)(c) appealing the determination of the utilization review agent, or if payment of an approved claim or complaint in accordance with 452 MCR 1.07 under the provisions of M.G.L. c. 152, Secs. (8)(4) and/or 10 use complain for 110 or 115 on DIA website at Injured employees may be liable for care subsequent to adverse determinations if they have been notified of that adverse determination. 2.3 The school of the reviewer

302 Addendum Tennessee Claims 1.0 Notifications of review determinations must be compliant with Rule Specifically: 2.0 The determination shall consider only the medical necessity, appropriateness, efficientcy, and quality of the recommended treatment for the employee s condition. 3.0 The determination must contain specific and detailed reasons for any denial. 4.0 Notice of any adverse determination must contain the name, address, telephone number and qualifications of the clinical peer reviewer. 5.0 Notice of any denial must include a list of all records and supplemental material reviewed. 6.0 Notice of any denial must include an appeal form prescribed by the Division. 7.0 Determination letters and appeal forms must be transmitted to the treating physician, employee and employer

303 Addendum Texas Claims 1.0 For Texas claims, notice of approval determinations will include: 1.1 The specific health care approved; 1.2 The approved number of treatments and the specific period of time to complete the treatments; 1.3 A notice of any dispute regarding the denial of compensability or liability or an unresolved dispute of the extent of or relatedness to the compensable injury. 2.0 For Texas claims, notice of adverse determinations will include: 2.1 The principal reason for the adverse determination; 2.2 The clinical basis for the adverse determination; 2.3 A description or the source of the screening criteria that were utilized as guidelines in making the adverse determination; 2.4 A plain language description of the complaint and appeal/reconsideration process; 2.5 Notification of the availability of an Independent Review after reconsideration of a denial or after the initial adverse determination for life threatening conditions and the procedures to obtain the review. 3.0 For Texas claims, there shall be no notifications of extension of review due date; determination letters of treatment plan modification; determination letters of conditionally non-certified status; or notices of review hold by client. None of the processes described in such notice are consistent with the statutory requirements of utilization review process in Texas

304 Addendum Utah Claims 1.0 Review correspondence on Utah claims must be compliant with R Specifically: 2.0 Notice of an original adverse determination must include the review criteria used to make the decision; must be accompanied by Form 223; and must be sent to the requesting provider and the claimant (patient). 3.0 Notice of an adverse determination on appeal must include the review criteria used to make the decision; must be accompanied by Form 223; and must be sent to the requesting provider, the claimant (patient), and the Commission

305 Utilization Management Turn Around Times CID Management Policy No Revision: 6.2 Revision Date:5/14/2012 Page 1 of 10 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines for review timeframes. It addresses the following time frames: standard, expedited, rush, and stat which shall apply to requests for authorization, appeals consideration or re-considerations. It also details the mechanism used to respond on an urgent basis to situations that pose an immediate threat to the health and safety of patients. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /24/2006 Revised Revision /26/2006 Revised Revision /15/2007 Revised Revision /05/2007 Revised Revision /01/2008 Revised Revision /12/2009 Revised Revision /08/2010 Reviewed Revision /28/2011 Revised Revision /14/2011 Revised Revision /24/2012 Revised Revision /14/2012 Revised 3.0 Persons Affected This policy affects all CID employees and contractors who participate in the utilization management operations. 4.0 Policy The policy of CID Management is to perform reviews in a timely fashion remaining compliant with all required laws and regulations. It is further the policy of CID Management to perform reviews in a timely fashion with consideration given to the medical condition of the patient. These timeframes apply to requests for authorization, appeals consideration, and re-consideration

306 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 CID defines its timeframes for utilization management for all reviews (prospective, concurrent and retrospective) as: Standard goal It is CID s intention to complete all reviews within 2 business days of receipt of all necessary information; even if requirements below in through are less stringent. This standard is a goal for timeliness, and is not a process requirement. Deadlines indicated below in through are mandatory, and must be complied with Expedited (Urgent or Emergent situation posing threat to health or life of patient) - within 4-6 hours of receipt, as possible. Process described below in Section Rush by midnight next business day Stat by midnight same business day Prospective, concurrent and retrospective reviews shall be completed within the earlier of: the deadline that is consistent with URAC standards; or the requirements of the jurisdiction of the claim. See addenda attached to Policy Timeframe extension for request for information In the event that there is insufficient information to complete a determination, and a written request for information has been sent to the health care provider and the patient, the deadline for completing the review will be extended. The length of such extension will comply with URAC standards if permitted within the jurisdiction of the claim; and otherwise will be consistent with the requirements of the jurisdiction. In the event that the requested information is provided prior to the extended deadline, the review shall be completed by the date consistent with earlier of URAC standards or the requirements of the claim jurisdiction. Such time frame extensions shall not be permitted for Expedited or Concurrent review Timeframe extension for reasons other than request for information There shall be no extension of review timeframe for any cause other than a request for information

307 6.2 Requesting physicians and/or clients shall be required to indicate the requested turn around time (standard, expedited, rush, stat) for review of a request for authorization, appeals consideration or re-consideration. If no timeframe is indicated, it shall be concluded that a standard turn around time is requested. 6.3 Upon receipt of a request for authorization, appeals consideration, or reconsideration, the CID staff shall review the following if applicable: if the request is prospective/concurrent/retrospective, the date the request was received by the client, the date the client sent a notification of extension of review due date, the date the client received additional information, the date the request was received by CID. Based on this information, and in full consideration to the prevailing utilization management laws and regulations, the appropriate due date shall be determined for the review 6.4 The CID staff shall then review the submitted documents to determine if the submitter has requested a standard, expedited, rush, or stat request. If the requested response date is earlier than the due date calculated in 6.3, then the due date shall be updated accordingly. If not, the due date calculated in 6.3 shall be retained. 6.5 The Director of Production shall oversee reviews in progress to ensure their completion by the due date. 6.6 Urgent Situations Posing an Immediate Threat to the Health and Safety of Patients (a.k.a. emergency health care services ) If a situation presents where a party communicates to CID that the health or safety of a patient is under immediate threat, the call shall be transferred directly to the Clinical Director, in his/her absence, to the Director of Production The Clinical Director, or Director of Production, shall immediately inform the requesting party that future denial of payment for emergency care may never be based on lack of prior authorization, and that emergency services provided may be reviewed retrospectively based on medical necessity at the time the services were provided. In the event that the requesting party desires prior authorization, utilization review shall proceed as described in through The Clinical Director, or Director of Production, assign the initial clinical reviewer, clinical peer reviewer, and QAQC reviewer that are immediately available for reviews. The availability of each reviewer shall be confirmed by the Clinical Director or Director of Production by telephone The Clinical Director, or Director of Production, shall evaluate the progress of the review by checking its status at intervals not to exceed 30 minutes

308 6.6.5 Immediately upon reaching a determination, the CID system shall generate a determination letter that shall be immediately faxed to the provider Immediately upon noting a determination has been reached, the Clinical Director, or Director of Production, shall contact the requesting provider via telephone to verify the receipt of the determination to ensure its arrival

309 Addendum URAC timeliness standards 1.0 Consistent with URAC WCUM 6.0 standards 17 through 19, the following completion deadlines will be met on all utilization review, except in jurisdictions with stricter requirements. 1.1 Prospective review: Excluding expedited review, the due date for prospective review is 15 calendar days after the receipt of the request for review by CID. 1.2 Concurrent review: Excluding expedited review, the due date for concurrent review is the earlier of: 1 calendar day prior to the start date of the requested extension of inpatient care; or15 calendar days after the receipt of the request for review by CID. Excluding expedited review, in the event that the requested extension of impatient care is received less than 1 business day prior to the start date of the requested extension of inpatient care, the due date shall be 1 business day after the receipt of the request for review by CID. 1.3 Retrospective review: The due date for retrospective review is 30 calendar days after the receipt of the request for review by CID. 2.0 Completion deadlines indicated above in 1.0 may be extended upon written request for additional information 2.1 Extension of deadline arising from request for information: The due date for completion of review shall be extended at least 45 calendar days, and no more than 60 calendar days, on issuance of a written request for additional information. No such extension shall be permitted for Concurrent or Expedited review. 2.2 If information sufficient to complete a determination of medical necessity is received prior to the extended due date, a new due date shall be calculated as follows: Prospective: The due date for prospective review is 15 calendar days after the receipt by CID of the additional information Retrospective: The due date for retrospective review is 30 calendar days after the receipt by CID of the additional information. 2.3 If the reasonable information requested is not received by 45 calendar days from the request for information, a Clinical Peer Reviewer or the Medical Director may issue a Conditional non-certification or a Non-certification, as permitted by jurisdictional requirements

310 Addendum California Claims 1.0 Consistent with the Cervantes decision, prospective reviews of requests that include spinal surgery shall be made in a timely fashion that is appropriate for the nature of the injured workers condition, not to exceed five (5) business days from the date of receipt of the written request for authorization. 1.1 If appropriate information, which is necessary to render a decision, is not provided with the original request for authorization, such information may be requested by a reviewer or non-physician reviewer within five (5) business days from the date of receipt of the written request for authorization. 1.2 If the reasonable information is received prior to the tenth (10 th ) calendar day following the date of receipt of the written request for authorization, the reviewer shall make a decision no later than ten (10) calendar days of the receipt of the original request for authorization. 1.3 If the reasonable information requested is not received within 10 calendar days of the date of the original request for authorization, a reviewer may deny the request with the stated condition that the request will be reconsidered upon receipt of the information requested. 1.4 In no event shall the determination be made more than 10 calendar days from the date of receipt of the original request for authorization from the health care provider. 1.5 If the review is expedited, the decision shall be made in a timely fashion appropriate to the injured worker s condition, not to exceed 72 hours after the receipt of the written information reasonably necessary to make the determination. 2.0 Prospective reviews shall be made in a timely fashion that is appropriate for the nature of the injured workers condition, not to exceed five (5) business days from the date of receipt of the written request for authorization. 2.1 If appropriate information, which is necessary to render a decision, is not provided with the original request for authorization, such information may be requested by a reviewer or non-physician reviewer within five (5) business days from the date of receipt of the written request for authorization. 2.2 If the reasonable information is received prior to the fourteenth (14 th ) calendar day following the date of receipt of the written request for authorization, the reviewer shall make a decision within five (5) business days of the receipt of the information.. In no event shall the determination be made more than 14 days from the date of receipt of the original request for authorization by the health care provider. 2.3 If the reasonable information requested is not received within 14 calendar days of the date of the original request for authorization, a reviewer may deny the request with

311 the stated condition that the request will be reconsidered upon receipt of the information requested. 2.4 In no event shall the determination be made more than 14 calendar days from the date of receipt of the original request for authorization from the health care provider. 2.5 If the review is expedited, the decision shall be made in a timely fashion appropriate to the injured worker s condition, not to exceed 72 hours after the receipt of the written information reasonably necessary to make the determination. 3.0 Concurrent reviews shall be made in a timely fashion that is appropriate for the nature of the injured workers condition, not to exceed five (5) business days from the date of receipt of the written request for authorization. 3.1 If appropriate information, which is necessary to render a decision, is not provided with the original request for authorization, such information may be requested by a reviewer or non-physician reviewer within five (5) business days from the date of receipt of the written request for authorization. 3.2 If the reasonable information is received prior to the fourteenth (14 th ) calendar day following the date of receipt of the written request for authorization, the reviewer shall make a decision within five (5) business days of the receipt of the information.. In no event shall the determination be made more than 14 days from the date of receipt of the original request for authorization by the health care provider. 3.3 If the reasonable information requested is not received within 14 calendar days of the date of the original request for authorization, a reviewer may deny the request with the stated condition that the request will be reconsidered upon receipt of the information requested. 3.4 In no event shall the determination be made more than 14 calendar days from the date of receipt of the original request for authorization from the health care provider. 3.5 If the review is expedited, the decision shall be made in a timely fashion appropriate to the injured worker s condition, not to exceed 72 hours after the receipt of the written information reasonably necessary to make the determination. 4.0 For retrospective reviews, decisions shall be communicated to the requesting physician within 30 days of receipt of the medical information that is reasonably necessary to make this determination. 4.1 If appropriate information, which is necessary to render a decision, is not provided with the original request for authorization, such information may be requested by a reviewer or non-physician reviewer within thirty (30) calendar days from the date of receipt of the written request for authorization

312 4.2 If the reasonable information is received prior to the thirtieth (30 th ) calendar day following the date of receipt of the written request for authorization, the reviewer shall make a decision within thirty (30) calendar days of the receipt of the information. 4.3 If the reasonable information requested is not received within 30 calendar days of the date of the original request for authorization, the reviewer may deny the request with the stated condition that the request will be reconsidered upon receipt of the information requested

313 Addendum Massachusetts Claims 1.0 For prospective reviews, the review shall be completed within two business days of the received of the request and the receipt of all information necessary to complete the review. 1.1 If additional information is required, the reviewer shall request the information prior to the end of the second business day following receipt of the request. The reviewer shall specify that if the required medical information is not received on or before the seventh (7 th ) business day from the date of the issuance of the request letter, then the UR reviewer shall issue the determination based upon the existing medical/clinical information. 1.2 If the additional information is received on or before the seventh (7 th ) business day, then the review shall be completed within two business days of the receipt of all information necessary to complete the review. 1.3 If the additional information is not received on or before the seventh (7 th ) business day, then the review shall be completed by the Medical Director, or School-to-School reviewer, within two business days of the seventh (7 th ) business day after the request for information. 2.0 For concurrent reviews, the review shall be completed one (1) business day prior to the start / implementation date for the ongoing care provided that the ordering practitioner has submitted the written request to utilization review at least three (3) business days prior to the start / implementation date. If the ordering practitioner fails to submit the written request to utilization review at least three (3) business days prior to the start / implementation date, then the review shall be completed within five (5) business days of the receipt of request from the ordering practitioner. 2.1 If additional information is required, the reviewer shall request the information prior to the end of the second business day following receipt of the request. The reviewer shall specify that if the required medical information is not received on or before the due date of the review, as calculated in point 2.0 of this section, then the UR reviewer shall issue the determination based upon the existing medical/clinical information. 2.2 If the additional information is received on or before the due date review, as calculated in point 2.0 of this section, then the review shall be completed by the due date of the review. 2.3 If the additional information is received on or before the due date review, as calculated in point 2.0 of this section, then the review shall be completed by the Medical Director, or School-to-School reviewer, by the due date of the review. 3.0 For retrospective reviews, the review shall be completed within twenty (20) business days of the received of the request and the receipt of all information necessary to complete the review

314 3.1 If additional information is required, the reviewer shall request the information prior to the end of the fifth (5 th ) business day following receipt of the request. The reviewer shall specify that if the required medical information is not received on or before the thirtieth (30 th ) business day from the date of the issuance of the request letter, then the UR reviewer shall issue the determination based upon the existing medical/clinical information. 3.2 If the additional information is received on or before the thirtieth (30 th ) business day, then the review shall be completed within five (5) business days of the receipt of all information necessary to complete the review. 3.3 If the additional information is not received on or before the thirtieth (30 th ) business day, then the review shall be completed by the Medical Director, or School-to-School reviewer, within five (5) business days of the thirtieth (30 th ) business day after the request for information. 4.0 For appeals of adverse determinations regarding prospective or concurrent requests, the review shall be completed within two (2) business days from the initiation of the appeal, unless the ordering provider agrees to a different time period. 5.0 For appeals of adverse determinations regarding retrospective requests, the review shall be completed no later than twenty (20) calendar days from the date the appeal is filed

315 Addendum Tennessee Claims 1.0 If there is sufficient information to complete the review, then the determination must be transmitted within 7 business days of the receipt of the case from the employer. 2.0 If there is insufficient information to complete the determination, a written request for information must be sent to the authorized treating physician. The remaining time to complete the review is tolled until the authorized treating physician responds, or until 5 business days have passed, whichever occurs first. When either of these events occurs, the review must be completed with the portion of the original 7 business days remaining

316 Addendum Texas Claims 1.0 For reviews of requests associated with claims within the jurisdiction of Texas, the review shall be completed within the timelines provided herein: For non-hcn (non certified workers compensation health care network) reviews, the timeframes for determination are: 1. Pre-authorization within 3 working days of receipt of the request 2. Concurrent review (excluding inpatient stay) within 3 working days of receipt of the request 3. Concurrent inpatient stay within 1 working day of the receipt of the request. Expedited inpatient stay requests will also be reviewed within 1 working day of the receipt of the request. If the proposed health care services involve post-stabilization treatment or a life-threatening condition, CID must transmit to the requesting provider a determination not to exceed one hour from receipt of the request. 4. Expedited- as soon as possible but no later than within 72 hours of receipt of request. Expedited requests for inpatient stay are excluded from this timeframe. 5. Emergency care- will not be subjected to preauthorization, may be reviewed retrospectively 6. Retrospective will be processed in accordance with the claim filing requirements described in Texas Labor Code and in accordance with 28 TAC, Chapter 133 Subchapter C. Timeframes for reconsiderations are: 1. Pre-authorization within 5 working days of receipt of the request for reconsideration 2. Concurrent review (excluding inpatient stay) within 3 working days of receipt of the request 3. Concurrent inpatient stay within 1 working day of the receipt of the request. Expedited inpatient stay requests will also be reviewed within 1 working day of the receipt of the request. 4. Expedited- as soon as possible but no later than within 72 hours of receipt of request for reconsideration. Expedited requests for inpatient stay are excluded from this timeframe. 5. Emergency care- will not be subjected to preauthorization, may be reviewed retrospectively. 6. Retrospective will be processed in accordance with the claim filing requirements described in Texas Labor Code and in accordance with 28 TAC, Chapter 133 Subchapter C. For HCN reviews, the timeframes for determinations are: 1. Pre-authorization within 3 calendar days of receipt of the request 2. Concurrent review (excluding inpatient stay) within 3 calendar days of receipt of the request 3. Concurrent inpatient stay within 24 hours of the receipt of the request. Expedited inpatient stay requests will also be reviewed within 24 hours of the receipt of the

317 request. If the proposed health care services involve post-stabilization treatment or a life-threatening condition, CID must transmit to the requesting provider a determination not to exceed one hour from receipt of the request. 4. Expedited- as soon as possible but no later than within 72 hours of receipt of request. Expedited requests for inpatient stay are excluded from this timeframe. 5. Emergency care- will not be subjected to preauthorization, may be reviewed retrospectively 6. Retrospective will be processed in accordance with the claim filing requirements described in Texas Labor Code and in accordance with 28 TAC, Chapter 133 Subchapter C. Timeframes for reconsiderations are: 1. Pre-authorization within 5 working days of receipt of the request for reconsideration 2. Concurrent review (excluding inpatient stay) within 3 working days of receipt of the request 3. Concurrent inpatient stay within 1 working day of the receipt of the request. Expedited inpatient stay requests will also be reviewed within 1 working day of the receipt of the request. 4. Expedited- as soon as possible but no later than within 72 hours of receipt of request for reconsideration. Expedited requests for inpatient stay are excluded from this timeframe. 5. Emergency care- will not be subjected to preauthorization, may be reviewed retrospectively 6. Retrospective will be processed in accordance with the claim filing requirements described in Texas Labor Code and in accordance with 28 TAC, Chapter 133 Subchapter C. 2.0 Prospective or concurrent requests for post stabilization care subsequent to emergency treatment shall be treated in the same manner as requests involving Urgent Situations, and shall be processed as described in Section 6.6 of Policy Determinations regarding prospective or concurrent requests for post stabilization care are to be provided within 1 hour of receipt of request. Retrospective requests for post stabilization care subsequent to emergency treatment shall be reviewed using the standards and timelines applicable to routine retrospective reviews

318 Addendum Utah Claims 1.0 Consistent with R (B), notice of completed review determination on Level I (original) review must be transmitted within 5 business days of the request for authorization. 2.0 Notice of completed review determination on Level II (appeal) review must be transmitted within 5 business days of the treating physician s request for review

319 Quality Assurance Quality Control CID Management Policy No Revision: 4.1 Revision Date: 6/9/2008 Page 1 of 5 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which quality assurance and quality control shall happen in the utilization management process at CID. It also details the structure and responsibilities of the Quality Assurance / Quality Control (QAQC) Committee. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /29/2008 Revised Revision /09/2008 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /26/2011 Reviewed Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects all employees and independent contractors who participate in performing utilization review at CID. 4.0 Policy The policy of CID Management is to ensure that reviews are completed with the highest quality by creating a QAQC program to monitor CID processes, provide feedback to the employees and contractors as necessary, and continually improve CID utilization management operations. It is further the policy of CID Management that a high quality product shall be the goal of every employee and contractor affiliated with our organization. 5.0 Definitions Definitions of terms are set forth in Policy

320 6.0 Procedures 6.1 Quality Assurance / Quality Control Committee The QAQC Committee has been granted the authority for quality management by the CID Executive Committee, including both Managing Directors and the Clinical Director On a quarterly basis, the QAQC Committee shall meet Each meeting of the QAQC Committee will be maintained in approved meeting minutes The QAQC Committee shall be comprised of the Clinical Director (Ex Officio) who serves as the committee s chair, the Director of Clinical Operations (Ex Officio), a rotating (1 year term) Director of Production, a rotating (1 year term) clinical staff member, and a rotating (1 year term) Non-CID representative. The clinical staff member may be an initial clinical reviewer, a clinical peer reviewer, or a QAQC reviewer. The Non- CID representative shall meet the professional requirements of a clinical peer reviewer The scope and objective of the QAQC Committee is to continually strive to improve the overall quality and accuracy of all reviews produced by CID The QAQC Committee will develop, monitor progress of, and update as necessary, quality improvement goals. These goals will be used as benchmarks, along with the QAQC project status reports, to evaluate the effectiveness of the QAQC program. The program s effectiveness will be reported in a QAQC Program Evaluation presented to the Executive Committee each year in the month of December The QAQC Committee shall review policies, regulations, and procedures concerning quality assurance and quality control in the utilization management operations The QAQC Committee shall provide guidance to staff on quality management projects, their scope, progress, and outcome, as well as the implementations of revised policies and procedures, as necessary. Following the completion of QAQC projects CID staff will be briefed on the results from the project via summary or in-office meeting The QAQC Committee shall develop and approve projects to monitor quality of utilization management operations

321 The Quality Assurance / Quality Control Committee shall review any QAQC projects currently in progress and shall utilize any information found within these projects to develop recommendations to modify existing Policies or Procedures to fine-tune the utilization management operations The Quality Assurance Quality Control Committee shall pass these recommendations to the Utilization Management Policies and Procedures Committee as well as to the Medical Director and Clinical Director The Utilization Management Policies and Procedures Committee shall review the recommendations and shall develop any changes to existing Policies and Procedures as deemed necessary. These changes shall be forwarded to the Medical Director and Clinical Director for final review and edit prior to being implemented CID will administer the CID Management Confidential Survey each year to all clients by mail. The QAQC Committee will be given the summary report of the CID Management Confidential Survey results each year upon compilation. The Committee will review this summary and recommend and develop QAQC projects for improvement of client satisfaction scores if a deficit in client satisfaction is noted In addition to other aspects of the survey summary report, the summary specifically notes details regarding the ability of consumers/clients to access services (Question #1 and 9 on the survey). If clients are unsatisfied with access to services an investigation by the Clinical Director or Director of Clinical Operations will be conducted. If needed, a quality improvement project (QIP) will be initiated with specific goals and statistically valid measurements. The results of such a QIP are to be reported to the QAQC Committee and the Executive Committee upon its completion Annually, during the month of December, the results of the daily QAQC program and the quarterly QAQC program will be reported to the Executive Committee by the Director of Clinical Operations (a standing member of the Executive Committee). Any comments, concerns, or directives will be reported back to the QAQC and Utilization Management Policy and Procedure Committees. Reports will be presented to the Executive Committee by the Director of Clinical Operations during the course of the year if QAQC issues arise that are unresolved at the secondand third-level committee level. 6.2 Daily Quality Assurance/Quality Control Program. The objective of the daily QAQC program is to provide the resources and staff to review the critical aspects of all

322 outbound reviews. By performing this QAQC check CID decreases errors, omissions, internal inconsistencies, inappropriate guideline referencing, etc Following completion of reviews, initial clinical reviewers and clinical peer reviewers shall mark their reviews as Released to QAQC The CID system shall migrate these reviews to the assigned QAQC Reviewer s in-box QAQC Reviewers shall perform day to day quality assurance and quality control monitoring of all reviews in their in-box. This monitoring shall include: Reviewing internal consistency within the review to ensure that the review does not contradict itself. In the event that there is an inconsistency between determination language and the reviewer s button selection of determination type, if the language clearly indicates the reviewer s intent then the inconsistency shall be resolved according to procedure If the intent of the clinical reviewer is not clearly reflected in the determination language, then the conflict inconsistency shall be resolved according to procedure Reviewing completeness of the review to ensure that it addresses all elements of care requested by the requesting physician Reviewing guidelines applied for relevance to the requested care Reviewing guidelines for appropriate referencing Reviewing completion criteria and savings estimate for accuracy Reviewing the grammar, punctuation, and spelling If the QAQC Reviewer notes non-material changes, such as spelling, grammar, or punctuation, they shall make the non-material changes to the review and shall release the review to the client If the QAQC Reviewer notes material changes, such as incomplete reviews or incorrect guidelines, they shall re-assign the review to the initial clinical reviewer or clinical peer reviewer for correction The QAQC Reviewers shall note any common errors of specific initial clinical reviewers or clinical peer reviewers and shall communicate this to the Clinical Director

323 6.2.7 If the QAQC Reviewers shall note any common errors of specific initial clinical reviewers or clinical peer reviewers, the Clinical Director shall contact the specific initial clinical reviewer or clinical peer reviewer to address and resolve these issues. 6.3 Quarterly Quality Assurance/Quality Control Program On a quarterly basis, the Quality Assurance/Quality Control Committee shall meet. Details of the meeting s agenda, charter, participants, goals, etc is noted above it section A standing agenda item at the quarterly meetings will be an analysis of all complaints, grievances, and appeals. For each complaint or grievance all materials will be presented and the course of action, outcome, and resolution will be discussed. The total number of reviews requested as well as the number and percentages of reviews certified, conditionally non-certified, non-certified, appeals certified, appeals conditionally noncertified, and appeals non-certified will be presented and discussed. Reference and comparison to past review percentages will be conducted for tracking of rates and trends. 6.4 Annually, during the month of December, the results of the daily QAQC program and the quarterly QAQC Committee meeting minutes will be presented to the Executive Committee by the Director of Clinical Operations (a standing member of the Executive Committee) in the form of a QAQC Program Evaluation. Any comments, concerns, or directives will be reported back to the QAQC and Utilization Management Policy and Procedure Committees in writing. 6.5 The Executive Committee can request reports, meeting minutes, or other materials from the QAQC Committee at any time to ensure accountability. 6.6 Reports will be presented to the Executive Committee by the Director of Clinical Operations during the course of the year if QAQC issues arise that are unresolved at the second- and third-level committee level

324 Utilization Management Business Hours CID Management Policy No Revision: 3.2 Revision Date: 6/22/2009 Page 1 of 7 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines outlining CID Management s business hours for utilization management operations. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /06/2008 Revised Revision /19/2009 Reviewed Revision /22/2009 Revised Revision /08/2010 Reviewed Revision /27/2011 Reviewed Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects all CID employees and contractors who perform utilization management operations. 4.0 Policy The policy of CID Management is to maintain business hours between 9:00 a.m. and 5:30 p.m. on all business days in all time zones in which CID conducts business. For the purpose of this policy, business days are defined as any day not defined as a holiday, or optional bank holiday, within the CA Civil Code which states: 4.1 Civil Code 7. Holidays within the meaning of this code are every Sunday and such other days as are specified or provided for as holidays in the Government Code of the State of California

325 5.0 Definitions 4.2 Civil Code 7.1. Optional bank holidays within the meaning of Section 9 are: o Any closing of a bank because of an extraordinary situation, as that term is defined in the Bank Extraordinary Situation Closing Act (Chapter 20 (commencing with Section 3600) of Division 1 of the Financial Code). o Every Saturday o Every Sunday o January 1 st o The third Monday in January, known as Dr. Martin Luther King, Jr. Day o February 12, known as Lincoln Day o The third Monday in February o The last Monday in May o July 4 th o The first Monday in September o September 9 th, known as Admission Day o The second Monday in October, known as Columbus Day o November 11 th, known as Veteran s Day o December 25 th o Good Friday from 12 noon until closing o The Thursday in November appointed as Thanksgiving Day o Any Monday following any Sunday on which January 1 st, February 12 th, July 4 th, September 9 th, November 11 th, or December 25 th falls. o Any Friday preceding any Saturday on which July 4 th, September 9 th, or December 25 th falls. Definitions of terms are set forth in Policy Procedures 6.1 The CID Clinical Director and Senior Utilization Review Managers shall meet in December to set the following year s business day schedule. 6.2 The Senior Utilization Review Manager shall schedule utilization review non-clinical administrative staff to ensure the office is staffed for business operations between 8:30 a.m. and 5:30 p.m. local time in all time zones in which CID maintains business operations The Senior Utilization Review Manager shall report to the Clinical Director and Director of Clinical Operations on a quarterly basis any instances in which no staff were available during business hours, as well as the cause of any such lapse in staffing. 6.3 The Clinical Director shall schedule initial clinical reviewers and clinical peer reviewers to ensure utilization management functions may be performed every business day of the year

326 Addendum State of Illinois (205 ILCS 630/17) (from Ch. 17, par. 2201) Sec. 17. Holidays. (a) The following days shall be legal holidays in the State of Illinois upon which day a bank may, but is not required to, remain closed: the first day of January (New Year's Day); the third Monday in January (observance of Martin Luther King, Jr.'s birthday); the twelfth day in February (Abraham Lincoln's birthday); the third Monday in February (Presidents Day); the first Monday in March (observance of Casimir Pulaski's birthday); the Friday preceding Easter Sunday (Good Friday); the last Monday of May (Memorial Day); the fourth day of July (Independence Day); the first Monday in September (Labor Day); the second Monday in October (Columbus Day); the eleventh day of November (Veterans' Day); the fourth Thursday in November (Thanksgiving Day); the twenty fifth day in December (Christmas Day); the days upon which the general elections for members of the House of Representatives are held, and any day proclaimed by the Governor of this State as a legal holiday. From 12 o'clock noon to 12 o'clock midnight of each Saturday shall be considered a half holiday. In addition to such holidays and half holidays, a bank may select one day of the week to remain closed, as provided in subsection (b) of this Section

327 Addendum State of Massachusetts MGL Chapter 4, Section 7 Eighteenth, "Legal holiday'' shall include January first, July fourth, November eleventh, and Christmas Day, or the day following when any of said days occurs on Sunday, and the third Monday in January, the third Monday in February, the third Monday in April, the last Monday in May, the first Monday in September, the second Monday in October, and Thanksgiving Day. "Legal holiday'' shall also include, with respect to Suffolk county only, Evacuation Day, on March seventeenth, and Bunker Hill Day, on June seventeenth, or the day following when said days occur on Sunday; provided, however, that all state and municipal agencies, authorities, quasi-public entities or other offices located in Suffolk county shall be open for business and appropriately staffed on Evacuation Day, on March seventeenth, and Bunker Hill Day, on June seventeenth, and that section forty-five of chapter one hundred and forty-nine shall not apply to Evacuation Day, on March seventeenth, and Bunker Hill Day, on June seventeenth, or the day following when said days occur on Sunday. Eighteenth A, "Commemoration day'' shall include March fifteenth, in honor of Peter Francisco day, May twentieth, in honor of General Marquis de Lafayette and May twenty-ninth, in honor of the birthday of President John F. Kennedy. The governor shall issue a proclamation in connection with each such commemoration day. Eighteenth B, "Legislative body'', when used in connection with the operation of municipal governments shall include that agency of the municipal government which is empowered to enact ordinances or by-laws, adopt an annual budget and other spending authorizations, loan orders, bond authorizations and other financial matters and whether styled a city council, board of aldermen, town council, town meeting or by any other title

328 Addendum State of Tennessee Legal holidays. January 1; the third Monday in January, Martin Luther King, Jr. Day ; the third Monday in February, known as Washington Day ; the last Monday in May, known as Memorial or Decoration Day ; July 4; the first Monday in September, known as Labor Day ; the second Monday in October, known as Columbus Day ; November 11, known as Veterans' Day ; the fourth Thursday in November, known as Thanksgiving Day ; December 25; and Good Friday; and when any one (1) of these days falls on Sunday, then the following Monday shall be substituted; and when any of these days falls on Saturday, then the preceding Friday shall be substituted; also, all days appointed by the governor or by the president of the United States as days of fasting or thanksgiving, and all days set apart by law for holding county, state, or national elections, throughout this state, are made legal holidays, and the period from twelve o'clock (12:00) noon to twelve o'clock (12:00) midnight of each Saturday which is not a holiday is made a half-holiday, on which holidays and half-holidays all public offices of this state may be closed and business of every character, at the option of the parties in interest of the same, may be suspended

329 Addendum State of Texas 1.0 Consistent with 6 GC , the following dates not included in the body of Policy 5000 are considered legal holidays in Texas: 1.1 the 19th day of January, "Confederate Heroes Day," in honor of Jefferson Davis, Robert E. Lee, and other Confederate heroes 1.2 the second day of March, "Texas Independence Day 1.3 the 21st day of April, "San Jacinto Day" 1.4 the 19th day of June, "Emancipation Day in Texas," in honor of the emancipation of the slaves in Texas in the 27th day of August, "Lyndon Baines Johnson Day," in observance of the birthday of Lyndon Baines Johnson 1.6 the Friday after Thanksgiving Day 1.7 the 24th day of December 1.8 the 26th day of December 2.0 Consistent with 6 GC , the following dates listed within the body of Policy 5000 are not considered legal holidays in Texas, and CID staff must therefore be available during legal business hours on these days: 2.1 February 12, known as Lincoln Day 2.2 September 9 th, known as Admission Day 2.3 The second Monday in October, known as Columbus Day

330 Addendum State of Utah Section 301 Legal holidays -- Personal preference day -- Governor authorized to declare additional days. 63G Legal holidays -- Personal preference day -- Governor authorized to declare additional days. (1) (a) The following-named days are legal holidays in this state: (i) every Sunday; (ii) January 1, called New Year's Day; (iii) the third Monday of January, called Dr. Martin Luther King, Jr. Day; (iv) the third Monday of February, called Washington and Lincoln Day; (v) the last Monday of May, called Memorial Day; (vi) July 4, called Independence Day; (vii) July 24, called Pioneer Day; (viii) the first Monday of September, called Labor Day; (ix) the second Monday of October, called Columbus Day; (x) November 11, called Veterans' Day; (xi) the fourth Thursday of November, called Thanksgiving Day; (xii) December 25, called Christmas; and (xiii) all days which may be set apart by the President of the United States, or the governor of this state by proclamation as days of fast or thanksgiving. (b) If any of the holidays under Subsection (1)(a), except the first mentioned, namely Sunday, falls on Sunday, then the following Monday shall be the holiday. (c) If any of the holidays under Subsection (1)(a) falls on Saturday the preceding Friday shall be the holiday. (d) Each employee may select one additional day, called Personal Preference Day, to be scheduled pursuant to rules adopted by the Department of Human Resource Management. (2) (a) Whenever in the governor's opinion extraordinary conditions exist justifying the action, the governor may: (i) declare, by proclamation, legal holidays in addition to those holidays under Subsection (1); and (ii) limit the holidays to certain classes of business and activities to be designated by the governor. (b) A holiday may not extend for a longer period than 60 consecutive days. (c) Any holiday may be renewed for one or more periods not exceeding 30 days each as the governor may consider necessary, and any holiday may, by like proclamation, be terminated before the expiration of the period for which it was declared

331 Utilization Management In-Business Hours Communications Access CID Management Policy No Revision: 3.1 Revision Date: 5/1/2008 Page 1 of 3 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which CID shall make itself available for communications from clients and stakeholders 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /01/2008 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /27/2011 Reviewed Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects all CID employees and contractors who perform utilization management operations. 4.0 Policy The policy of CID Management is to provide access to the utilization management department during normal business hours, by a toll free phone number, toll free fax number, and US postal address. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 The Director of Production shall ensure that CID maintains a toll free phone number for use in utilization review operations

332 6.2 The Director of Production shall ensure that CID maintains a toll free fax number for use in utilization review operations. 6.3 The Clinical Director shall ensure that the toll free phone number, toll free fax number and US postal address are printed on all forms and all written communications generated by CID. 6.4 The Director of Customer Relations shall ensure that all clients have a copy of CID s toll free number, toll free fax number and US postal address for distribution as they deem appropriate. 6.5 The Clinical Director shall ensure that the complete Policies and Procedures will be made available to the public on request

333 Addendum California 1.0 The Clinical Director shall ensure that the current Utilization Review Plan, as filed with the Administrative Director, will be made available to the public on request

334 Utilization Management Communications Response CID Management Policy No Revision: 3.0 Revision Date: 6/5/07 Page 1 of 2 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which CID employees or contractors respond to mail, voice mail, fax, or messages. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /27/2011 Reviewed Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects all CID employees and contractors who perform utilization management operations. 4.0 Policy The policy of CID Management is to return mail inquiries, voice mail messages, messages, or fax messages within 1 business day of receipt. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 The Director of Production shall schedule non-clinical administrative staff to check the mailbox once per business day after standard US post delivery time

335 6.2 The Director of Production shall schedule non-clinical administrative staff to check the general voice mail message box four times per business day including: immediately upon arrival in the office; mid-morning; mid afternoon; end of business day. 6.3 The Director of Production shall schedule non-clinical administrative staff to check the general in-box four times per business day including: immediately upon arrival in the office; mid-morning; mid afternoon; end of business day. 6.4 Each non-clinical administrative staff member shall check their personal voice mail message box four times per business day including: immediately upon arrival in the office; mid-morning; mid afternoon; end of business day. 6.5 Each non-clinical administrative staff member shall check their in-box four times per business day including: immediately upon arrival in the office; midmorning; mid afternoon; end of business day. 6.6 Each clinical contractor or staff member, including but not limited to, initial clinical reviewer and clinical peer reviewer, shall check their in-box once per business day. 6.7 All CID employees and contractors shall reply to mail, voice mail, , or fax messages within 1 business day of receipt. 6.8 All CID employees and contractors shall reply to mail, voice mail, or fax messages during reasonable and normal business hours unless otherwise mutually agreed to by the party to be contacted. 6.9 All CID employees and contractors shall log the date and content of received mail, voice mail, or fax message within the CID system, if the communication directly referenced a review or claim in the CID system All CID employees and contractors shall log the date and content of their response to the mail, voice mail, or fax message within the CID system, if the communication directly referenced a review or claim in the CID system

336 Utilization Management After Hours Communications CID Management Policy No Revision: 3.1 Revision Date: 6/6/08 Page 1 of 2 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which after hours communications shall be handled. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /06/2008 Revised Revision /19/2009 Reviewed Revision /08/2010 Reviewed Revision /27/2011 Reviewed Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects all CID employees and contractors who perform utilization management operations. 4.0 Policy The policy of CID Management is to maintain 24-hour access to secure electronic submission, fax machines and voice mail systems for providers or clients to submit requests for authorization, appeals consideration or re-considerations outside of regular business hours as defined in CID Policy It is further the policy of CID to maintain a 24-hour find-me-follow-me access line for clients to contact the Clinical Director or Senior Utilization Review Staff in case of emergency. 5.0 Definitions Definitions of terms are set forth in Policy

337 6.0 Procedures 6.1 The Director of Production shall ensure that CID maintains a 24-hour voice mail service that allows clients and review stakeholders to leave messages after regular business hours. 6.2 The Director of Production shall ensure that CID maintains a 24-hour fax service that allows clients and review stakeholders to fax requests for authorization, appeals consideration or re-consideration after regular business hours. 6.3 The Director of Production shall ensure that CID maintains a 24-hour secured electronic submission service that allows clients and review stakeholders to submit requests for authorization, appeals consideration, or re-consideration after regular business hours. 6.4 The Director of Production shall report on a quarterly basis to the Clinical Director and Director of Clinical Operations all known instances of outages of service on the voice mail, fax and electronic access services described above in sections 6.1, 6.2 and 6.3, and all known instances of complaints regarding lack of access to these services. 6.5 The Clinical Director shall ensure that CID maintains a 24-hour find-me-follow-me access line for clients to contact the Clinical Director or Senior Utilization Review Staff in case of emergency. 6.6 The Clinical Director shall ensure that all clients have access and training on how to utilize the 24-hour find-me-follow-me access line in cases of emergency

338 Utilization Management Communications Etiquette CID Management Policy No Revision: 3.0 Revision Date: 6/5/07 Page 1 of 2 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which CID employees and contractors shall conduct themselves in communications with any party. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /27/2011 Reviewed Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects all CID employees and contractors who perform utilization management operations. 4.0 Policy The policy of CID Management is to provide professional and courteous communications to all parties. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 All CID employees and contractors shall maintain the highest levels of professionalism in all communications which shall include: Answering communications promptly and courteously

339 6.1.2 Providing proper identification, including own name (full or partial), job title, and company name with placing and answering communications Showing respect and courtesy by using the customer s full name, title or rank, except where the circumstances are such that the use of the callers first name would be more appropriate Ensuring that transferred calls are answered before disconnecting from the customer Handing customer communications in a thoughtful, considerate, patient and helpful manner

340 Marketing and Communications CID Management Policy No Revision: 6.0 Revision Date: 3/14/2011 Page 1 of 3 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which all marketing and communications materials will be produced. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /24/2006 Revised 6.3 Revision /26/2006 Revised Revision /05/2007 Revised Revision /29/2008 Revised Revision /06/2008 Revised Revision /14/2009 Reviewed Revision /08/2010 Reviewed Revision /26/2011 Reviewed Revision /14/2011 Revised Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects all CID employees and contractors who are involved in the production of marketing and communications materials. This includes, but is not limited to, the Managing Directors, the Clinical Director, Operations Director, and any marketing subcontractors. The public and potential clients are also affected. These clients include requesting physicians, nurse case managers, claim s administrators, and health insurance companies. 4.0 Policy The policy of CID Management is to clearly and accurately communicate information about our services to clients. 5.0 Definitions Definitions of terms are set forth in Policy

341 6.0 Procedures 6.1 CID does direct marketing through individual mailings, ings, e-newsletters, print collateral, Google adwords, website postings, and attendance/representation at conventions. 6.2 CID sometimes partners with companies who are similarly positioned in the worker s compensation market, such as CompIQ and Interplan, to help market our product along with their own at conventions, sales calls, etc. 6.3 CID utilizes two independent review groups prior to approval and production of any marketing materials. Only upon separate approval by these two review bodies (at least one person from each group) are marketing materials produced and distributed. These two independent review bodies are: Clinical Group, consisting of member who have clinical experience and are licensed health care providers. This group shall review all marketing materials for accuracy and intent from a clinical perspective, and shall ensure that: The information presented clearly and accurately communicates information regarding CID s services The information does not misrepresent the organization s services Business Group. This shall review all marketing materials for accuracy, lucidity, and intent, from a business perspective, and shall ensure that: The information presented clearly and accurately communicates information regarding CID s services The information does not misrepresent the organization s services. 6.4 All marketing materials to be used on a continuing basis are to be reviewed as described above on at least an annual basis. 6.5 New marketing materials shall not be distributed until both review groups agree that there are no errors in content. Established materials that are found to have errors on periodic re-review are to be corrected as rapidly as possible or withdrawn from use. 6.6 Any complaints or grievances related to marketing or misrepresentation are handled through the grievance process (see Policy 1500) and are maintained for future reference

342 Addenda to Policy 5050: Group Rosters as of 4/24/2012 Clinical Group: Todd Andrew Lisa Shaw O Connor Jason Vanderford Robert Ward Business Group Steven Cardinale Rick Leinwohl

343 Utilization Management On Site Reviews CID Management Policy No Revision: 3.1 Revision Date: 3/12/2009 Page 1 of 3 Jonathan Rutchik, MD Medical Director, CID Robert W. Ward, DC Clinical Director, CID 1.0 Purpose This policy establishes guidelines by which CID employees and contractors function when performing on-site reviews. 2.0 Revision History Revision /15/2006 New Policy/Initial Implementation Revision /26/2006 Revised Revision /05/2007 Revised Revision /12/2009 Revised Revision /08/2010 Reviewed Revision /14/2011 Reviewed Revision /24/2012 Reviewed 3.0 Persons Affected This policy affects all CID employees or contractors who perform utilization management operations on-site. 4.0 Policy The policy of CID Management is to represent a professional and respectful presence when performing reviews onsite. 5.0 Definitions Definitions of terms are set forth in Policy Procedures 6.1 Prior to scheduling employees or contractors to work on-site, the Clinical Director or Director of Production shall contact the client to determine any facility or organization requirements that may exist

344 6.2 The Clinical Director or Director of Production shall write up specific procedures CID employees or contractors must follow for each specific organization or facility. 6.3 A copy of the written procedures shall be forwarded to the organization or facility for review, comment and update as necessary. 6.4 The Clinical Director or Director of Production shall review the written procedures with all CID employees and contractors who will be on-site at that organization or facility. A hard copy of these procedures will be provided to the CID employees and contractors for reference. 6.5 When performing utilization management functions on-site, CID employees and contractors shall provide the organization or facility in which they will be working at least one business day notice of their arrival unless otherwise agreed. 6.6 When performing utilization management functions on-site, CID employees and contractors shall check in with designated staff or personnel upon their arrival and shall check out with designated staff or personnel upon their departure. 6.7 When performing utilization management functions on-site, CID employees and contractors shall conduct themselves in a professional manner obeying any and all rules and regulations of the organization or facility in which they are working. 6.8 When performing utilization management functions on-site, CID employees and contractors shall carry their CID picture ID identifying their position with CID. The picture ID shall be worn in a conspicuous location. When performing utilization management functions on-site in Texas, the CID picture ID shall also include CID s Texas Department of Insurance identification number. 6.9 When performing utilization management functions on-site, CID employees and contractors shall wear appropriate facility-supplied identification tags in a conspicuous location, if so requested CID staff shall not observe, participate in, record or otherwise be present during an injured employee s examination, treatment, procedure or therapy unless approved by the injured employee and the treating physician or modified by contract CID staff will not require as a condition of treatment approval or for any other reason, the observation of a psychotherapy session or the submission or review of a mental health therapist s process or progress notes CID staff, if so requested, will agree that the medical records remain available in the designated area during the onsite review and that reasonable hospital administrative procedures shall be followed so as not to disrupt hospital operations or patient care

345 CID Management On-site Picture ID