Organization Determination Process Definition Organization Determination: Any determination made by a Medicare health plan with respect to any of the following: Payment for temporarily out of the area renal dialysis services, emergency services, poststabilization care, or urgently needed services; Payment for any other health services furnished by a provider other than the Medicare health plan that the enrollee believes are covered under Medicare, or, if not covered under Medicare, should have been furnished, arranged for, or reimbursed by the Medicare health plan; The Medicare health plan s refusal to provide or pay for services, in whole or in part, including the type or level of services, that the enrollee believes should be furnished or arranged for by the Medicare health plan; Discontinuation of a service if the enrollee believes that continuation of the services is medically necessary; or Failure of the Medicare health plan to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the enrollee with timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee. Process An organization determination can be requested orally or in writing (includes email or facsimile) by a member, legal representative or any provider that furnishes, or intends to furnish, services to the member. An organization determination is any determination (approval or denial) made by the Plan or delegate with respect to the areas listed in the definition above. Golden State Medicare Health Plan (plan) provides Medicare-covered benefits according to the Medicare National Coverage Determinations Manual. This manual is the primary record of Medicare national coverage policies, and includes a discussion of the circumstances under which items and services are covered. This manual may be accessed at http://www.cms.hhs.gov/manuals/iom/list.asp H2241_001_7013_3_2012 File & Use 10052011 1 P a g e
How to contact us when you are asking for a coverage decision about your medical care Coverage Decisions for Medical Care CALL (562) 799-0319 Calls to this number are not toll free, unless dialed locally. Hours of operation are 8 a.m. to 8 p.m. Monday through Friday, (weekend hours during the enrollment period). (877) 541-4111 Calls to this number are free. Hours of operation are 8 a.m. to 8 p.m. Monday through Friday, (weekend hours during the enrollment period). TTY (877) 551-4111 FAX (562) 799-0507 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are free. Hours of operation are 8 a.m. to 8 p.m. Monday through Friday, (weekend hours during the enrollment period). WRITE MEDICARE WEBSITE Golden State Medicare Health Plan c/o Member Services 3010 Old Ranch Parkway Suite 260 Seal Beach, CA 90740 You can submit a complaint about Golden State Medicare Health Plan directly to Medicare. To submit an online complaint to Medicare, go to https://www.medicare.gov/medicarecomplaintform/home.aspx For more information on asking for coverage decisions about your medical care, see Chapter 9 of the Evidence of Coverage document. Termination of Services When the organization determination is the termination of services specific to home health agencies (HHAs), skilled nursing facilities (SNFs) and comprehensive outpatient rehabilitation facilities (CORFs) the following procedures apply. A termination of service is the discharge of a member from covered provider services or discontinuation of covered provider services when the member has been authorized by the Plan, either directly or by delegation, to receive an ongoing course of treatment from that provider. Termination includes cessation of coverage at the end of a course of treatment preauthorized in a discrete increment, regardless of whether the member agrees that such services should end. Hospitals must notify Medicare Advantage (MA) member who are hospitalized about their discharge appeal rights. If the member requests an immediate QIO review, the Plan or delegate will deliver a detailed notice of Medicare non-coverage (NOMNC) to the member explaining 2 P a g e
why services are no longer reasonable and necessary or are no longer covered. The notice of Medicare non-coverage (NOMNC) must be issued no later than two days before the proposed end of hospital coverage. If the member's services are expected to be fewer than two days in duration, the provider should notify the member at the time of admission. The written notice must include the following elements: The use of a standardized NOMNC in accordance with CMS guidelines; The reason why inpatient hospital care is no longer needed or covered; The date that coverage of services end; The effective date of the member's liability for continued inpatient care; and A description of the member's right to a fast-track appeal, how to contact Quality Improvement Organization (QIO), a member's right (but not obligation) to submit evidence showing that services should continue and the availability of other appeal procedures if the member fails to meet the deadline for a fast-track QIO appeal. Delivery of the NOMNC is not valid unless: The member (or authorized representative) has signed and dated the notice to indicate that he or she has received the notice and can comprehend its contents; and The notice contains the language specified above. If the provider is unable to deliver a NOMNC to a member or representative in person, then the provider should telephone the representative to advise him or her when the member s services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested. The date that someone at the representative s address signs (or refuses to sign) the receipt is the date of receipt. When notices are returned by the post office with no indication of a refusal date, the member s liability starts on the second working day after the provider s mailing date. Members who wish to exercise the right to an immediate review, must submit a request to the QIO no later than the day of discharge. The request may be in writing or by telephone. They will not be financially responsible for the days they stay in the hospital during the QIO review (except for applicable cost shares). The Plan or delegate (IPA/MG/hospital) will supply any requested information, including a copy of the DNOD to the QIO no later than noon of the day after the QIO notification. The QIO must notify the Plan that the member has filed a request for immediate review. The Plan or delegate will deliver the Detailed Notice of Discharge (DNOD) to the member as soon as possible but no later than noon of the day after notification. The Plan will supply necessary information to conduct a review. The QIO must make a determination and notify the member, the hospital and the Plan by close of business of the first working day after it receives all necessary information. The Detailed Notice of Discharge (DNOD) includes: The specific reasons for the denial 3 P a g e
An explanation of member rights to request a reconsideration An explanation of both the standard and expedited reconsideration processes, including the member's right to, and conditions for, obtaining an expedited reconsideration and appeal process According to CMS requirements, failure to provide a member with timely notification of an organization determination as specified in this section, constitutes an adverse organization determination and may be appealed. Expedited Determination An expedited determination can be requested by a member, legal representative or a physician (regardless of whether the physician is affiliated with the Plan). This does not include requests for payment of services already furnished. An appropriate reason to expedite a review is when the wait time for a standard determination could seriously jeopardize the member's life, health or ability to regain maximum function. Actions following a denial for a request for an expedited determination include: Automatically transfer a request to the standard timeframe and make the determination within the 14-day timeframe. The 14-day period begins with the day the Plan receives the request for expedited determination. Give the member prompt oral notice of the denial and subsequently deliver, within 3 calendar days, a written letter that: Explains that the Plan will process the request using the 14-day timeframe for standard determinations; Informs the member of the right to file an expedited grievance if he or she disagrees with the Plan's decision not to expedite; and Informs the member of the right to resubmit a request for an expedited determination with any physician's support; and Provides instructions about the grievance process and its timeframes. Notification of an Adverse Expedited Organization Determination The standardized denial notice form must provide: The specific reason for the denial that takes into account the member s presenting medical condition, disabilities, and special language requirements, if any; Information regarding the member s right to a standard or expedited reconsideration and the right to appoint a representative to file an appeal on the member s behalf; A description of both the standard and expedited reconsideration processes including conditions for obtaining an expedited reconsideration, and the other elements of the appeals process; and The member s right to submit additional evidence in writing or in person. When the Plan or delegate first notifies a member of an adverse expedited determination orally, written confirmation will be mailed to the member within 3 calendar days of the oral notification. 4 P a g e
Time Frames When a party has made a request for reconsideration, the Plan will notify the member of its determination as expeditiously as possible. The member's health condition is considered, but a determination will be made no later than 14 calendar days after the date of receipt of the request for a standard organization determination. The Plan may extend the timeframe by up to 14 calendar days if the member requests the extension or if the organization justifies a need for additional information and how the delay is in the interest of the member (for example, the receipt of additional medical evidence from noncontract providers may change a decision to deny). A determination will be made no later than 72-hour after the date of receipt of the request for an expedited organization determination. The 72-hour period begins when the request is received by the utilization department designated by the Plan or delegate. The member will be notified in writing of the reasons for the delay, and inform the member of the right to file an expedited grievance if he or she disagrees with the decision to grant an extension. If the Plan or delegate requires medical information from non-contracted providers to make a decision, the Plan or delegate must request the necessary information from the non-contracted provider within 24 hours of the initial request for an expedited organization determination. Noncontracted providers must make reasonable and diligent efforts to expeditiously gather and forward all necessary information to assist the Plan or delegate in meeting the required time frame. Denial of Coverage Denial of coverage based on a lack of medical necessity (or any substantively equivalent term used to describe the concept of medical necessity), must be made by a physician with expertise in the field of medicine that is appropriate for the services at issue. The physician making the determination need not, in all cases, be of the same specialty or subspecialty as the treating physician. If the Plan decides to deny service or payment in whole or in part, or if a member disagrees with the Plan's decision to discontinue or reduce the level of care for an ongoing course of treatment, the organization must give the member written notice of the determination. The Plan and delegates will utilize approved notice language in a readable and understandable form for all non-coverage denials (i.e., service, claims). Denial letters will include: The specific reasons for the denial An explanation of member rights to request a reconsideration An explanation of both the standard and expedited reconsideration processes, including the member's right to, and conditions for, obtaining an expedited reconsideration and appeal process (service denial) An explanation of the standard reconsideration process and appeal process (payment denials) 5 P a g e
Pre-Service Denials If a member requests a standard pre-service reconsideration and during the processing time the member obtains the service before the Plan completes its reconsideration determination, the Plan will dismiss the pre-service reconsideration request and the Plan will forwards the appeal case with supporting documentation to the IRE for dismissal. Reconsideration The reconsideration consists of a review of an adverse organization determination or termination of services decision, the evidence and findings upon which it was based and any other evidence that the parties submit or that is obtained by the Plan or delegate, the QIO or the independent review entity. See the appeals process for further information on reconsiderations. 6 P a g e