Health UM Accreditation v7.4. Workers Compensation UM Accreditation v7.4. Copyright 2018 URAC All Rights Reserved

Transcription

1 Health UM Accreditation v7.4 Workers Compensation UM Accreditation v7.4 Copyright 2018 URAC All Rights Reserved

2 Learning Objectives Attendees at this webinar should be able to: Understand the accreditation standards. Determine the documentation needed to submit with the application. Prepare for URAC s validation review.

3 AccreditNet Application Instruction Booklet Note: 10 documents limitation per standard. AccreditNet Tutorial video is available on the AccreditNet homepage and as a URAC s Education elearning course

4 Scoring Methodology Six distinct scoring categories 1 = Emerging practice 2 = Basic infrastructure 3 = Promotes quality 4 = Key stakeholder right/empowers consumers M = Mandatory element with a direct or significant impact on consumer safety and welfare L = Leading Indicator not weighted (optional element) All mandatory elements must be scored as Met in order to achieve a Full Accreditation

5 Focus Area UM-CS: Utilization Management Criteria and Services

6 Standard UM-CS 1: Review Criteria

7 Review Criteria UM-CS 1-1: Review Criteria Requirements (HUM 1/WCUM 1) The organization utilizes explicit clinical review criteria or scripts that are: a. Developed with involvement from appropriate providers or prescribers with current knowledge relevant to the criteria or scripts under review; [3] b. Based on current clinical principles and processes; [3] c. Evaluated at least annually and updated, if necessary, by: [3] i. The organization itself; and [3] ii. Appropriate, actively-practicing physicians, pharmacists, and other providers with current knowledge relevant to the criteria or scripts under review; and [M] d. Approved by the medical director (or equivalent designate), clinical director (or equivalent designate), P&T Committee, or other equivalent clinical oversight body. [M]

8 Standard UM-CS 2: Accessibility of Review Services

9 Accessibility of Review Services UM-CS 2-1: Access to Review Staff (HUM 2/WCUM 2) The organization provides access to its review staff by a toll-free or collect telephone line at a minimum from 9:00am to 4:00pm of each normal business day in each time zone where the organization conducts at least two percent of its review activities. [4] Two percent of review activities may be calculated as follows: % reviews in time zone = Number of reviews originating in a particular time zone X 100 divided by the total number of reviews.

10 Accessibility of Review Services UM-CS 2-2: Review Service Communication and Time Frames (HUM 3/WCUM 3) The organization maintains processes to: a. Receive communications from providers and patients during the business day and after business hours; [4] b. Respond to communications within one business day; and [4] c. Conduct its outgoing communications related to utilization management during providers reasonable and normal business hours, unless otherwise mutually agreed. [4] Communications include telephonic and electronic correspondence. The organization defines with methods to use. HUM 3(b) is the only URAC Health UM standard that uses business days.

11 Accessibility of Review Services UM-CS 2-3: Review Services Disclosure (HUM 4/WCUM 4) The organization: a. Requires utilization management staff to identify themselves by name, title, and organization name; and [2] b. Upon request, verbally informs patients, facility personnel, the attending physician and other ordering providers and health professionals of specific utilization management requirements and procedures. [4] First or last name or another identifier is acceptable. Must provide their job title or clinical title.

12 Standard UM-CS 3: On-Site Review Services

13 On-site Review Services UM-CS 3-1: On-Site Review Requirements (HUM 5/WCUM 5) For verification review services, the organization: a. Requires on-site reviewers to carry a picture ID with full name and the name of the organization; [2] b. Schedules reviews at least one business day in advance, unless otherwise agreed; and [4] c. Requires the on-site reviewers to follow reasonable hospital or facility procedures, including checking-in with designated hospital or facility personnel. [4]

14 On-Site Review Services (Formerly HUM 6 N/A) This standard number is reserved to synchronize with URAC s Workers Compensation Utilization Management Standards. UM-CS 3-2: Initiation of Review Process (WCUM 6/HUM is N/A) The organization allows any appropriate person to initiate the certification review process, as determined by state law or regulation or by workers compensation insurer or claims administrator. Appropriate persons may include but are not limited to the worker or a representative of the worker, the claims adjustor, the facility rendering service, the provider, or a state regulator. [4]

15 Standard UM-CS 4: Initial Screening

16 Initial Screening UM-CS 4-1: Limitations in Use of Non-Clinical Staff (HUM 7/WCUM 7) For initial screening, the organization limits use of nonclinical administrative staff to: a. Performance of review of service request for completeness of information; [2] b. Collection and transfer of non-clinical data; [2] c. Acquisition of structured clinical data; and [2] d. Activities that do not require evaluation or interpretation of clinical information. [M] Element a is N/A for Workers Compensation.

17 What information can the non-clinical staff obtain? General Non-clinical staff may not conduct any activities that require interpretation of clinical information including, but not limited to the choosing of a set of criteria to use for handling a request for health care services or treatments Specific Examples Demographic information Employer name Insurance information Date of surgery/procedure Physician name Facility name

18 Initial Screening UM-CS 4-2: Pre-Review Screening Staff Oversight (HUM 8/WCUM 8) The organization ensures that licensed health professionals are available to non-clinical administrative staff while performing initial screening. [M] The supervisor of the non-clinical staff does not have to be a clinical person. However, there should be a process in place for availability of clinical reviewers for oversight and follow-up for clinical-related questions or issues.

19 Initial Screening UM-CS 4-3: Pre-Review Screening Non-Certifications (HUM 9/WCUM 9) The organization does not issue noncertifications based on initial screening. [M] All medical necessity non-certifications must be done by a peer reviewer.

20 Evidence for Validation Review Clinical case records illustrating initiation of the review process, pre-review screening, and initial clinical review and non-certification process. Scripts or algorithms used for pre-review screening. Non-clinical staff will be randomly selected for interviews and observation.

21 Standard UM-CS 5: Initial Clinical Review

22 Initial Clinical Review UM-CS 5-1: Initial Clinical Review Qualifications (HUM 10/WCUM 10) Individuals who conduct initial clinical review possess an active professional license or certification: a. To practice as a health professional in a state or territory of the United States; and [M] b. With a scope of practice that is relevant to the clinical area(s) addressed in the initial review. [M] Unlike peer reviewers conducting peer clinical review and appeals, initial clinical reviewers can be located outside of the U.S. or its territories when performing an initial clinical review. NurSys can be used to primary source verify nursing licenses.

23 The United States and Its Territories U.S. Territories American Samoa Guam Northern Mariana Islands Puerto Rico U.S. Virgin Islands

24 Initial Clinical Review UM-CS 5-2: Initial Clinical Reviewer Resources (HUM 11/WCUM 11) Individuals who conduct initial clinical review have access to consultation with a: [3] a. Licensed doctor of medicine or doctor of osteopathic medicine; or b. Licensed health professional in the same licensure category as the ordering provider; or c. Health professional with the same clinical education as the ordering provider in clinical specialties where licensure is not issued. The standard does not require the health professional to be of the same specialty as the ordering provider.

25 Initial Clinical Review UM-CS 5-3: Initial Clinical Reviewer Non-Certifications (HUM 12/WCUM 12) The organization does not issue noncertifications based on initial clinical review. [M]

26 Focus Area UM-PCR: Peer Clinical Review

27 Standard UM-PCR 1: Peer Clinical Review

28 Peer Clinical Review UM-PCR 1-1: Peer Clinical Review Cases (HUM 13/WCUM 13) The organization conducts peer clinical reviews for all cases where a certification is not issued through initial clinical review or initial screening. [M] Clinical review conducted by appropriate health professionals when a request for an admission, procedure, or service was not approved during initial clinical review.

29 Peer Clinical Review UM-PCR 1-2: Peer Clinical Reviewer Qualifications (HUM 14/WCUM 14) Individuals who conduct peer clinical review are clinical peers who: a. Hold an active unrestricted license to practice medicine or a health profession in a state or territory of the United States; [M] b. Unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting a peer clinical review; [M] c. 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 [M] d. Hold a current and valid license: [M] i. In the same licensure category as the ordering provider; or ii. As a doctor of medicine or doctor of osteopathic medicine.

30 Peer Clinical Review UM-PCR 1-3: DRUM Reviewer Qualifications (HUM 15/WCUM 15) When conducting drug utilization review: a. In addition to the initial clinical reviewers described in UM 10, certifications (only) can be rendered by pharmacy technicians who: i. Follow HUM/WCUM 1 established criteria; and [M] ii. If required by state law, possess an active professional relevant license in good standing. [M]

31 Peer Clinical Review UM-PCR 1-3: DRUM Reviewer Qualifications (HUM 15/WCUM 15) b. In addition to the clinical peers described in UM 14, noncertifications (as well as certifications) can be rendered by pharmacists who: i. Hold an active, unrestricted license or certification to practice pharmacy in a state or territory of the United States; [M] ii. Unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting drug utilization review; [M] iii.may not conduct peer clinical review non-certifications for drug utilization management if prohibited by state utilization management laws; and [M] iv.may not conduct peer clinical review non-certifications for drug utilization management if the requesting party specifically requests a clinical peer. [M]

32 Peer Clinical Review UM-PCR 1-4: Prospective, Concurrent, and Retrospective DRUM (HUM 16/WCUM 16) The organization ensures drug utilization management mechanisms using the available information and data addressing the following, where appropriate: [M] a. Therapeutic appropriateness; b. Over and underutilization; c. Generic use; d. Therapeutic interchange; e. Duplication; f. Drug-disease contraindications; g. Drug-drug or drug-allergy interactions; h. Drug dosage; i. Duration of treatment; j. Clinical abuse or misuse; k. Drug-age precautions; l. Drug-gender precautions; m. Drug-pregnancy precautions; n. Regulatory limitations; and o. Benefit design. Typically embedded electronically in the claims software, clinical decision support tools, and/or clinical review tools and alerts the program staff to take action per the organization s policies and procedures.

33 Standard UM-PCR 2: Peer-to-Peer Conversation

34 Peer-to-Peer Conversation UM-PCR 2-1: Peer-to-Peer Conversation Availability (HUM 17/WCUM 17) Health professionals that conduct peer clinical review are available to discuss review determinations with attending physicians or other ordering providers. [4] Peer clinical review can occur by telephone, in person, or electronically. The goal of the peer-to-peer conversation is to allow the treating provider a chance to discuss a UM determination before the initiation of the appeal process.

35 Peer-to-Peer Conversation UM-PCR 2-2: Peer-to-Peer Conversation Alternate (HUM 18/WCUM 18) When a determination is made to issue a non-certification, and no peer-to-peer conversation has occurred: a. The organization provides, within one business day of a request by the attending physician or ordering provider, the opportunity to discuss the non-certification decision: i. With the clinical peer reviewer making the initial determination; ii. or [4] With a different clinical peer, if the original clinical peer reviewer cannot be available within one business day; and [4] b. If a peer-to-peer conversation or review of additional information does not result in a certification, the organization informs the provider and consumer of the right to initiate an appeal and the procedure to do so. [4]

36 Questions?

37 Focus Area UM-POL: UM Policies & Procedures

38 Standard UM-POL 1: Time Frames for Initial UM Decision

39 Time Frames for Initial UM Decision UM-POL 1-1: Prospective Review Time Frames (HUM 19/WCUM 19) For prospective review, the organization issues a determination: a. As soon as possible based on the clinical situation, but in no case later than 72 hours from the receipt of a request for a utilization management determination, if it is a case involving urgent care; or [4] b. Within 15 calendar days of the receipt of request for a utilization management determination, if it is a nonurgent case; and [4]

40 Time Frames for Initial UM Decision UM-POL 1-1: Prospective Review Time Frames (HUM 19/WCUM 19) For prospective review, the organization issues a determination: c. For non-urgent cases this period may be extended one time by the organization for up to 15 calendar days: i. Provided that the organization determines that an extension is necessary because of matters beyond the control of the organization; [4] ii. iii. Notifies the patient, prior to the expiration of the initial 15 calendar day period, of the circumstances requiring the extension and the date when the plan expects to make a decision; and [4] If a patient fails to submit necessary information to decide the case, the notice of extension must specifically describe the required information, and the patient must be given at least 45 calendar days from receipt of notice to respond to the plan request for more information.

41 Definition of 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 that: 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.

42 Time Frames for Initial UM Decision UM-POL 1-2: Retrospective Review Time Frames (HUM 20/WCUM 20) For retrospective review, the organization issues a determination: a. Within 30 calendar days of the receipt of request for a utilization management determination, and [3] b. This period may be extended one time by the organization for up to 15 calendar days: i. Provided that the organization determines that an extension is necessary because of matters beyond the control of the organization; [4] ii. Notifies the patient, prior to the expiration of the initial 30 calendar day period of the circumstances requiring the extension and the date when the plan expects to make a decision; and [4] iii. If a patient fails to submit necessary information to decide the case, the notice of extension must specifically describe the required information, and the patient must be given at least 45 calendar days from receipt of notice to respond to the plan request for more information. [4]

43 Time Frames for Initial UM Decision UM-POL 1-3: Concurrent Review Time Frames (HUM 21/WCUM 21) For concurrent review, the organization adheres to the following time frames: a. For reductions or terminations in a previously approved course of treatment, the organization issues the determination early enough to allow the patient to request a review and receive a decision before the reduction or termination occurs; and [4] b. For requests to extend a current course of treatment, the organization issues the determination within: i. 24 hours of the request for a utilization management determination, if it is a case involving urgent care and the request for extension was received at least 24 hours before the expiration of the currently certified period or treatments; or [4] ii. 72 hours of the request for a utilization management determination, if it is a case involving urgent care and the request for extension was received less than 24 hours before the expiration of the currently certified period or treatments. [4]

44 Standard UM-POL 2: Notice of Certification Decisions

45 Notice of Certification Decisions UM-POL 2-1: Certification Decision Notice and Tracking (HUM 22/WCUM 22) For certifications, the organization: a. Has a process for notification of the attending physician or other ordering provider, facility rendering service, and patient; [4] b. Includes tracking information (such as reference number) in the notice of certification; and [3] c. Upon request from the attending physician or other ordering provider, facility rendering service, or patient, provides written notification of any certification. [4] What are some examples of mechanisms used for notification of the certification decision?

46 Notice of Certification Decisions UM-POL 2-2: Continued Certification Decision Requirements (HUM 23/WCUM 23) Confirmation of certification for continued hospitalization or services includes the number of extended days or units of service, the next anticipated review point, the new total number of days or services approved, and the date of admission or onset of services. [3]

47 Standard UM-POL 3: Notice of Non-Certification Decisions

48 Notice of Non-Certification Decisions UM-POL 3-1: Written Notice of Non-Certification Decisions and Rationale (HUM 24/WCUM 24) For non-certifications, the organization issues written notification of the non-certification decision to the patient and attending physician or other ordering provider or facility rendering service that includes: a. The principle reasons for the determination not to certify; [4] b. A statement that the clinical rationale used in making the noncertification decision will be provided, in writing, upon request; and [4] c. Instructions for: i. Initiating an appeal of the non-certification; and [M] ii. Requesting a clinical rationale for the non-certification. [M]

49 Key Definitions Lack of medical necessity is not sufficient to meet the requirement for principal reason.

50 Time Frames for Initial UM Decision UM-POL 3-2: Clinical Rationale for Non-Certification Requirements (HUM 25/WCUM 25) Upon request from the patient, attending physician, or other ordering provider or facility rendering service, the organization provides specific clinical rationale upon which the non-certification was based. [4] The clinical rationale provides additional clarification of the clinical basis for a non-certification decision and specific reasons why the patient s symptoms did not meet the criteria.

51 Standard UM-POL 4: UM Policy

52 UM Policy UM-POL 4-1: Prospective Review Patient Safety (HUM 26/WCUM 26) To improve patient safety and reduce medical errors, the organization has implemented a mechanism to address potential safety issues identified during prospective review through to resolution. [M] What are some examples of potential patient safety issues that may be discovered during the prospective review process?

53 UM Policy UM-POL 4-2: Reversal of Certification Determination (HUM 27/WCUM 27) The organization does not reverse a certification determination unless it receives new information that is relevant to the certification and that was not available at the time of the original certification. [4] If the organization does not reverse certification decisions regardless of any new information provided, this must be indicated in a written policy statement.

54 UM Policy UM-POL 4-3: Frequency of Continued Reviews (HUM 28/WCUM 28) The organization ensures that the frequency of reviews for the extension of initial determinations is based on the severity or complexity of the patient s condition or on necessary treatment and discharge planning activity (i.e., not routinely conducted on a daily basis). [4] What are some examples of situations that impact the frequency of continued review?

55 Evidence for Validation Review Clinical case records illustrating continued stay review patterns. Review staff may be interviewed to determine what instructions they have been provided regarding the frequency of conducting concurrent reviews.

56 Standard UM-POL 5: Information upon which UM is Conducted

57 Information upon which UM is Conducted UM-POL 5-1: Scope of Review Information (HUM 29/WCUM 29) The organization, when conducting routine prospective review, concurrent review, or retrospective review: a. Accepts information from any reasonably reliable source that will assist in the certification process; [2] b. Collects only the information necessary to certify the admission, procedure or treatment, length of stay, or frequency or duration of services. [2] c. Does not routinely require hospitals, physicians, and other providers to numerically code diagnoses or procedures to be considered for certification, but may request such codes, if available; [4] WCUM = N/A

58 Information upon which UM is Conducted UM-POL 5-1: Scope of Review Information (HUM 29/WCUM 29) The organization, when conducting routine prospective review, concurrent review, or retrospective review: d. Does not routinely request copies of all medical records on all patients reviewed; [4] WCUM = N/A e. Requires only the section(s) of the medical record necessary in that specific case to certify medical necessity or appropriateness of the admission or extension of stay, frequency or duration of service, or length of anticipated inability to return to work; and [4] f. Administers a process to share all clinical and demographic information on individual patients among its various clinical and administrative departments that have a need to know, to avoid duplicate requests for information from enrollees or providers. [3]

59 Information upon which UM is Conducted UM-POL 5-2: Prospective and Concurrent Review Determinations (HUM 30/WCUM 30) For prospective review and concurrent review, the organization bases review determinations solely on the medical information obtained by the organization at the time of the review determination. [4] UM-POL 5-3: Retrospective Review Determinations (HUM 31/WCUM 31) For retrospective review, the organization bases review determinations solely on the medical information available to the attending physician or ordering provider at the time the medical care was provided. [4]

60 Information upon which UM is Conducted UM-POL 5-4: Lack of Information Policy and Procedures (HUM 32/WCUM 32) The organization implements policies and procedures to address situations in which it has insufficient information to conduct a review. Such policies and procedures provide for: a. Procedural time frames that are appropriate to the clinical circumstances of the review (i.e., prospective, concurrent, and retrospective reviews); [4] b. Resolution of cases in which the necessary information is not provided to the organization within specified time frames; and [4] c. Processes by which the organization issues an administrative non-certification due to lack of information. [4] Lack of Information Policy

61 Focus Area UM-APP: UM Appeals

62 Standard UM-APP 1: UM Appeals

63 UM Appeals UM-APP 1-1: Non-Certification Appeals Process (HUM 33/WCUM 33) The organization maintains a formal process to consider appeals of non-certifications that includes: a. The availability of standard appeal for non-urgent cases and expedited appeal for cases involving urgent care; and [M] b. Written appeals policies and procedures that: i. Clearly describe the appeal process, including the right to appeal of the patient, provider, or facility rendering service; [M] ii. Provide for explicit time frames for each stage of the appeal resolution process; and [M] iii. Are available, upon request, to any patient, provider, or facility rendering service. [M]

64 UM Appeals UM-APP 1-2: Appeals Process (HUM 34/WC is N/A) As part of the appeals process: a. The organization provides the patient, provider, or facility rendering service the opportunity to submit written comments, documents, records, and other information relating to the case; [M] b. Takes all such information into account during the appeals process without regard to whether such information was submitted or considered in the initial consideration of the case; and [M] c. In instance of a first level appeal, the organization implements the decision of the first level clinical appeal if it overturns the initial denial. [M] UM-APP 1-3: Appeals Process (WCUM 34/HUM is N/A) When applicable, the organization coordinates its appeal activities with regulatory appeals processes, which may be available to the worker. [4]

65 UM Appeals UM-APP 1-4: Appeal Peer Reviewer Qualifications (HUM 35/WCUM 35) Individuals who conduct appeal consideration are clinical peers who: a. Hold an active unrestricted license or certification to practice medicine or a health profession in a state or territory of the United States and are clinical peers; [M] b. Unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting appeal consideration; [M] c. Are in the same profession and in a similar specialty as typically manages the medical condition, procedure, or treatment as mutually deemed appropriate; [M] d. Are neither the individual who made the original noncertification, nor the subordinate of such an individual; and [M]

66 UM Appeals UM-APP 1-4: Appeal Peer Reviewer Qualifications (HUM 35/WCUM 35) Individuals who conduct appeal consideration are clinical peers who: e. Are board-certified (if applicable) by: [3] i. A specialty board approved by the American Board of Medical Specialties (doctors of medicine); or ii. iii. iv. The Advisory Board of Osteopathic Specialists from the major areas of clinical services (doctors of osteopathic medicine); The American Dental Association s (ADA) specialty boards or the American Board of General Dentistry (ABGD); or The American Board of Podiatric Surgery (ABPS) or the American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM).

67 UM Appeals UM-APP 1-5: Drug Utilization Management Appeals: Reviewer Qualifications (HUM 36/WCUM 36) In addition to the clinical peers described in standard UM 35, individuals who conduct drug utilization management appeal considerations include pharmacists who: a. Hold an active unrestricted license or certification to practice pharmacy in a state or territory of the United States; [M] b. Unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting appeal considerations; [M] c. Are neither the individual who made the original non-certification, nor the subordinate of such an individual; and [M] d. May not conduct drug utilization management appeal considerations if: i. Prohibited by state appeal laws; or [M] ii. The requesting party specifically requests a clinical peer. [M]

68 UM Appeals UM-APP 1-6: Reviewer Attestation Regarding Credentials and Knowledge (HUM 37/WCUM 37) For each appeal case they accept, reviewers attest to: a. Having a scope of licensure or certification that typically manages the medical condition, procedure, treatment, or issue under review; and [4] b. Current, relevant experience and/or knowledge to render a determination for the case under review. [4] Methods of documenting reviewer attestation include: electronic signature, wet signature, electronic or wet mark in a checkbox where the identity of the reviewer can be determined by name, or using a unique identifier assigned to an individual reviewer.

69 UM Appeals UM-APP 1-7: Expedited Appeals Process Time Frame (HUM 38/WCUM 38) Expedited appeals are completed with verbal notification of determination to the requesting party within 72 hours of the request followed by a written confirmation of the notification within three calendar days to the patient and attending physician or other ordering provider or facility rendering service. [M] Does 72 hours = 3 business days?

70 UM Appeals UM-APP 1-8: Standard Appeals Process Time Frame (HUM 39/WCUM 39) Standard appeals are completed, and written notification of the appeal decision issued, within 30 calendar days of the receipt of the request for appeal to the patient and attending physician or other ordering provider or facility rendering service. [M]

71 UM Appeals UM-APP 1-9: Written Notice of Upheld Non-Certifications (HUM 40/WCUM 40) For appeals determinations, the organization issues written notification of the adverse appeal decision to the patient and attending physician or other ordering provider or facility rendering service that includes: a. The principal reasons for the determination to uphold the noncertification; [4] b. A statement that the clinical rationale used in making the appeal decision will be provided, in writing, upon request; and [4] c. Information about additional appeal mechanisms available, if any. [4] Please define principal reason and clinical rationale.

72 UM Appeals UM-APP 1-10: Appeal Record Documentation (HUM 41/WCUM 41) The organization maintains records for each appeal that includes: a. The name of the patient/worker, provider, and/or facility rendering service; [3] b. Copies of all correspondence from the patient, provider, or facility rendering service and the organization regarding the appeal; [3] c. Dates of appeal reviews, documentation of actions taken, and final resolution; [3] d. Minutes or transcripts of appeal proceedings (if any); and [3] e. Name and credentials of the clinical peer that meets the qualifications in standard HUM/WCUM 35. [3]

73 File Review Sample Pointers For a new applicant, the time frame for sampling begins from the date that the applicant submitted their desktop review. For reaccreditation, time frame for sampling begins from the date of the last regular verification review. A sample is selected from the denial/appeal log. Case file review starts with the denial and goes through to the appeal determination to the member. Indicate on the denial/appeal universe if cases are standard or expedited. Only medical necessity appeals are reviewed. Be prepared to identify the ordering provider s specialty at the time of case review, which is needed to determine same/similar specialty match for an appeal.

74 Questions?

75 Thank you!