Subject: HEALTH PLAN OF SAN JOAQUIN tice of Action for Delayed, Denied, Modified, or Terminated Services Department: Medical Management Unit: Utilization Management Policy #: UM07 Effective Date: 02/01/1996 Applies To: Committee/Approval Date: QMUM 3/14; 11/14; 1/15; 03/16; 10/16 Review/Revision Dates: 09/01; 08/02; 10/04; 11/05; 09/08; 03/09; 7/12; 12/13; 9/14; 1/15; 10/15; 12/15; 03/16; 10/16 Medi-Cal X MCAP X TPA X PURPOSE (HPSJ) provides timely notification of tice of Action letters to providers and members for decisions on requested services. The Department of Health Care Services (DHCS) and Department of Managed Health Care (DMHC) require health plans to notify their members and providers when pre-service, concurrent or post-service authorization requests are delayed, denied, or modified. In addition, members and providers are notified when the health plan intends to take action to reduce or terminate services already being rendered. DEFINITIONS Administrative Criteria is criteria based on benefits or eligibility Appeal means a formal request by a Member, Subscriber or treating Practitioner for reconsideration of a utilization review decision to deny, modify, delay, or terminate health care services. Benefits Denial is the denial of a requested service that is specifically excluded from a member s benefit plan and is not covered by HPSJ under any circumstances. A benefit determination includes denial of requests for extension of treatments beyond the limitations and restrictions imposed in the member s benefit plan. Concurrent Review refers to utilization management that takes place during the provision of services, typically applied to the medical necessity of an inpatient hospital admission, residential behavioral healthcare, intensive outpatient behavioral healthcare and ongoing ambulatory care. Concurrent review may be a review for an extension of a previously approved, ongoing course of treatment or number of treatments. Emergent means an acute medical or psychiatric condition with symptoms that if left untreated might be life-threatening or, symptoms that if left untreated could result in serious deterioration of a member s health (see P&P UM04 Emergency Department Services). prior authorization is required. The prudent lay-person standard is followed to determine that the presenting complaint meets the definition of emergent. Delay refers to a postponed medical determination in order to obtain additional information to determine the medical necessity of an authorization request. Denial refers to a non-approval of an authorization request due to eligibility, benefit coverage, medical necessity or practitioner/provider contract status. Policies & Procedures Page 1 of 9
Evidence of Coverage (EOC) means any certificate, agreement, contract, brochure, or letter of entitlement issued to a subscriber or enrollee setting forth the coverage to which the subscriber or enrollee is entitled. Medical Necessity Criteria means written, objective criteria, based on sound scientific evidence, clinical principles, and expert opinion used to determine Medical Necessity. Medically Necessary means those reasonable and necessary services, procedures, treatments, supplies, devices, equipment, facilities, or drugs that a medical practitioner, exercising prudent clinical judgment, would provide to a member for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, or disease or its symptoms to protect life, to prevent significant illness or significant disability, or to alleviate severe pain that are: Consistent with generally accepted standards of medical practice: o o Generally accepted standards of medical practice means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, national physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. For drugs, this also includes relevant findings of government agencies, medical associations, national commissions, peer reviewed journals and authoritative compendia consulted in pharmaceutical determinations. Clinically appropriate in terms of type, frequency, extent, site, and duration and considered effective for the individual member s illness, injury, or disease: Individualized, specific, and consistent with the individual member s signs, symptoms, history, and diagnosis. Reasonably expected to help restore or maintain the individual member s health or to improve or prevent deterioration in the member s disorder or condition. t provided for the convenience of the member, physician, or other health care provider. t more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that member s illness, injury, or disease. Provided in the appropriate setting that balances safety, effectiveness, and efficiency. Modification An authorization which is approved in part of the actual or original request. The approval is changed or adjusted to meet guidelines based on medical review criteria to determine member progress and the need for additional services. Peer Reviewer means a physician or pharmacist, or non-physician doctoral-level practitioner bearing a valid unrestricted California license and who is qualified and competent to evaluate the specific clinical issue involved in a UM determination. Competence is determined by appropriate training, experience, and/or certification by the American Board of Medical Specialties. Practitioner means a professional who provides health care services. Practitioners are usually required to be licensed as required by law. Pre-Service Review means the formal process requiring a health care provider to obtain advance approval for coverage of specific services or procedures. Pre-service review allows for benefit Policies & Procedures Page 2 of 9
determination, determination of medical necessity and clinical appropriateness, level of care assessment, assignment of the length of stay for inpatient admissions, appropriate facility placement prior to the delivery of service, and identification of the intensity of case/care management that may be needed for optimal patient outcomes. Provider means any professional person, organization, health facility, or other person or institution licensed by the state to deliver or furnish health care services. NCQA considers a provider to be an institution or organization that provides services for members where examples of provides include hospitals and home health agencies. NCQA uses the term practitioner to refer to the professionals who provide health care services, but recognizes that a provider directory generally includes both providers and practitioners and the inclusive definition is more common usage. Post-Service Review/Retro Review refers to the process of making a medical necessity or coverage determination after care has been delivered. Reduction refers to an approval of a request for non-acute continuing services as defined in Title 22 CCR, Section 51003 (c) (1) at less than the amount or frequency requested and less than the amount or frequency approved on the immediately preceding authorization. Reduction is synonymous with modification in the authorization determination process. Routine means care or services required that are non-emergent and non-urgent where there is no anticipated decline of health that warrants expedited review. Urgent Care means: o o In the opinion of a Practitioner with knowledge of the Member s medical condition, would subject the Member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request or, In the opinion of a practitioner with knowledge of the member s medical or behavioral healthcare condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request. Utilization Management (UM) means the system of evaluating the necessity, appropriateness, and efficiency of health care services and intervening to positively influence utilization patterns. This includes determining the coverage for medical care services as well as providing any needed assistance to clinician or patient in cooperation with other parties, to ensure appropriate use of resources. POLICY A. Members will be notified in writing within two (2) working days of HPSJ s decision to delay, defer, deny, modify, reduce or terminate coverage for medical or pharmaceutical services. Members will be given an opportunity to appeal the action. B. Utilization Management staff will follow the review process and timeframes for routine and urgent pre-authorization requests as stated in policy and procedure UM 01. All denial determinations will be made by a physician... HPSJ provides practitioners with the opportunity to discuss any UM denial decision based on Medical Necessity with an appropriate Physician Reviewer. C. Utilization management decisions are based only on appropriateness of care, service and the existence of coverage. There are no rewards or incentives for practitioners or other individuals for issuing denials of coverage, service, or care. There are no financial Policies & Procedures Page 3 of 9
incentives for utilization management decision-makers to encourage decisions that would result in underutilization. PROCEDURE A. tice of Action Letters 1. Members are provided with written notification (tice of Action Letters) for denial, deferral, modification, and termination determinations which clearly document and communicate the reasons for the decision so that Members receive sufficient information in easily understandable language to be able to understand the decision and decide whether to Appeal the decision. 2. Requesting Practitioners are provided with written notification (tice of Action Letters) for denial, deferral, modification, and termination determinations, within twenty-four (24) hours of a determination, which clearly document the reasons for the decision so that Practitioners receive sufficient information in a timely manner and decide whether to Appeal the decision. B. Denials 1. Denial tice of Action (NOA) letters sent to Members and requesting Practitioners contain: a. The determination. b. The specific reasons for the determination in easily understandable language including the clinical reasons for a decision regarding medical necessity. In addition, the following information is contained for the specified circumstances: i. Medical Necessity Criteria t Met.: The notification must state how the reason for the determination pertains to the Member s particular case to ensure that Members and Practitioners understand why the decision was made and have enough information to make a decision about appealing the determination. ii. iii. Requested Information t Received: If there is NO clinical information whatsoever, the letter will note the inability to reference any specific Utilization Management Criteria. Condition or service is covered by another service agency and not by the Health Plan. Medication request is not a Formulary Drug: Appropriate alternative formulary medication will be indicated with a notation that the physician and pharmacy have been notified. c. A reference to the Medical Necessity Criteria, benefit provision, guideline, protocol, or other similar criteria, including a citation of the specific regulations or HPSJ s administrative procedures supporting the action on which the deferral, modification, denial, or termination decision is based. d. Information about how the member can obtain, free of charge, a copy of the actual Medical Necessity Criteria,, benefit provision, guideline, protocol, Policies & Procedures Page 4 of 9
or other similar criteria on which the deferral, modification, denial or terminate decision was based. e. All required DHCS/DMHC appeal requirements information applicable to the Medi-Cal member, including: i. A description of the appeal rights available to the member according to their product line, including the right to submit written comments, documents, or other information relevant to the appeal. f. A description of the expedited appeal process for urgent pre-service or urgent concurrent delays, denials, modifications, or terminations. g. The right to request an Independent Medical Review (IMR). h. For Medi-Cal members specifically: i. The member's right to, and method of obtaining, a fair hearing and expedited fair hearing to contest the denial, deferral, modification, or terminate action ii. iii. The member's right to represent himself/herself at the fair hearing or expedited fail hearing or to be represented by legal counsel, friend, or other spokesperson. The name and address, the state toll-free telephone number for obtaining information on legal service organizations for representation. i. For concurrent and post-service denials, denial NOA letters are not sent to Members who are not at financial risk. j. For urgent concurrent denial decisions at a hospital level of care, HPSJ may verbally inform the hospital UR department of the determination. This verbal notification is followed by a written notification to both the Hospital and the treating Practitioner. Practitioner notices may be sent to the hospital but must be addressed to the attention of the attending/treating practitioner. C. Reconsideration Process for Denials, Deferrals, Modifications, and Terminations 1. A requesting practitioner may call to discuss the case with a Peer Reviewer or may write to supply additional information for the Peer Reviewer. 2. HPSJ UM Department responds to reconsideration requests within one (1) business day of the receipt of the requesting Practitioner telephone call or written request. 3. If the Peer Reviewer reverses the original UM determination based on the discussion with, or additional information provided by, the Practitioner, the case will be closed. 4. If reconsideration does not resolve a difference of opinion, and the previous UM determination remains or a modification results, or if the Practitioner does not request reconsideration, the Practitioner may submit a request for review through Policies & Procedures Page 5 of 9
D. Delay/Defer the Provider Dispute process (see Policy #CLMS 07) or may Appeal on behalf of the member, if appropriate. 1. A Delay/Defer NOA letter will be generated and mailed to the Member and requesting Practitioner when: a. Additional clinical information is required to apply the UM criteria. These letters will contain the following: i. Reference to the clinical criteria that has not been met because of inadequate information. The letter must specifically describe the information needed in order to render a decision in a manner that the Member can understand what is needed. b. Consultation by an expert reviewer is necessary: i. The letter will explain why an expert reviewer is necessary and the date expected to make the final decision. Additional examination or tests that need to be performed. The letter will indicate the specific tests or exam needed and that when complete, to resubmit the request along with the test or exam findings. c. Referral is made to CCS for eligibility determination: E. Modification, Reduction i. The letter will state that the service requested is covered by the California Children s Services as a carve-out and the request has been forwarded to CCS for review and/or approval. The letter must inform the member that he/she will continue to receive medically necessary, benefit covered services from the health plan. 1. HPSJ will issue a NOA letter when it makes a decision to modify, or reduce, care or services. The time frame for such mailing is described in Policy #UM 01. a. The Modify, Reduce, Terminate NOA letter will include the Member s right to appeal and the appeal process the right to request an independent Medical Reviewer (IMR) F. Member Grievance and Appeals Processes Described 1. All NOA letters described in this policy will include a description of the Member appeal process, the right to a fair hearing, and the steps to take, including: a. How to file a Grievance or Appeal with HPSJ. b. How a fair hearing can be obtained from the state. c. That the Member may be either self-represent or be represented by an authorized third party such as legal counsel, relative, friend or other person. d. The time limits for filing a Grievance or Appeal and for requesting a fair hearing. e. The Department of Managed Health Care (DMHC) member notification information (Health and Safety Code, Section 1368.02). Policies & Procedures Page 6 of 9
2. The HPSJ Grievance Coordinator will handle all grievances filed by a Member, Member Representative, or Practitioner acting on behalf of the Member. G. Processing and Retention of tice of Action Letters (NOA s) 1. NOA letters will be processed as required in order to comply with timeliness standards. All NOA letters will be reviewed and signed by the Medical Director. 2. All NOA letters will include a direct telephone number for contacting the Medical Director. H. Quality Improvement Performance Measuring 1. On a quarterly basis five (5) randomly selected cases with associated letters from each utilization staff member will be audited for compliance with documentation standards and timeliness. 2. The audit results will be discussed with appropriate staff, aggregated, and included as part of the quality improvement data. 3. Appropriate action, such as staff education, counseling and/or disciplinary action, as appropriate to the situation, will take place as required when performance standards are not met. 4. Reports will be forwarded to the department director. I. UM Record Retention Requirements 1. UM Records, including any tices of Action letters, shall meet current federal, State, and DHCS Medi-Cal record retention requirements. 2. DHCS Medi-Cal record retention requirements are as follows: a. UM Records shall be maintained for a minimum of ten years from the end of the Fiscal Year: i. In which the date of the service occurred; ii. In which the record or data was created or applied; and for which the financial record was created or the Contract is terminated, or b. In the event HPSJ has been duly notified that DHCS, DHHS, DOJ, or the Comptroller General of the United States, or their duly authorized representatives, have commenced an audit or investigation of HPSJ s Agreement with DHCS for the provision of Medi-Cal Services, until such time as the matter under audit or investigation has been resolved, whichever is later. REFERENCE A. DHCS Contract, Exhibit A, Attachment 13, #8 B. Title 22, CCR, Sections 51014.1, 51014.2, 51003, 51303, 53894 C. Health and Safety Code, Sections 1368.02, 1367.01 D. DHCS MMCD ALL Plan Letter 05005 E. UM 01 Authorization and Referral Review F. UM 06 Medical Review Criteria G. UM 65 UM Appeals Policies & Procedures Page 7 of 9
H. NCQA Standard UM 2: Clinical Criteria for UM Decisions I. NCQA Standard UM 4: Appropriate Professionals J. NCQA Standard UM 5: Timeliness of UM Decisions K. NCQA Standard UM 6: Clinical Information L. NCQA Standard UM 7: Denial tices M. NCQA Standard UM 8: Policies for Appeals ATTACHMENTS tice of Action Letters Auditing Tool Approval: Signatures on File DHCS Contract Deliverables Contract Reference Date of Approval A.18.5 5/31/16 DHCS Unit Contract Reference Date of Approval DHCS Unit MMCD A.18.16 2/9/17 MMCD Policies & Procedures Page 8 of 9
tice of Action Letters Auditing Tool RO# # # # # # # # # The decision to Delay/Deny/Modify was made by the Medical Director or UM Physician Advisor for medical necessity? The decision to Delay/Deny/Modify was made within the TAT specific for the type of review as stated in UM 01 for Routine, Urgent or Emergent? 1. Complete reason for decision 2. Criteria Referenced 3. Copy of Criteria Available on Request free of charge 4. Availability of Physician Reviewer 5. Appeal Rights The NOA letter was processed within required TAT of 2 working days from the decision date? The appropriate physician phone # or designee signature is on the letter? The letter is written in easy to understand language? Cultural language needs appropriately identified? Audit rate for Employee % % % % % % % % Employee Name: Employee Name: Overall Score: % Title: Title: Corrective Action Required: Comments: If, Date Conducted: Policies & Procedures Page 9 of 9