File A Complaint: Utilization Review

Available to members of all health plans.

These are the procedures all plans, no matter what type, use to determine whether to allow a benefit, treatment or referral that you or your HCP requests based on whether that benefit, treatment or referral is medically necessary. If the plan denies a benefit, treatment or referral because the plan says it is not medically necessary, you have the right to question the plan’s decision through the UR appeal process. The plan must tell you how to file a UR appeal when they make this kind of decision. The plan’s UR procedures must also be described in your member handbook or contract.

The medical director, a licensed physician, must supervise and oversee the UR process. The details of the plan’s procedures must be filed with the State Health Department and available to you and to your HCPs.

How to use the Utilization Review Process:

Your health plan must have a toll free phone number, answered by real people, at least 5 days a week, during normal business hours. After hours, the plan must have a way for you to leave a message (voice mail, answering machine, etc.) and the plan must return your call within 1 business day. For example, if you leave a message on Friday night, the plan has to call you back on Monday.

If your HCP wants to extend your stay in a hospital or specialty care center (for example, a cancer institute or rehabilitation center) she/he must be able to contact a UR person at the plan for approval 24 hours a day, 7 days a week.

Who performs the Utilization Review (UR)?

The law says that people who are trained in intake and trained to collect information and who are supervised by a licensed HCP can take an initial request for UR. If the UR approves your or your HCP’s request, that decision can be made by a licensed HCP.

But, if the plan denies your or your HCP’s request, which is known as an adverse determination, then that decision must be made by a physician, or, if the request was made by another type of HCP, the decision must be made by a licensed HCP who is in the same or similar field as the provider who requested the benefit. For example, if the request was made by a social worker, the adverse determination must be made by a social worker at the plan or by a physician. Physicians can always make adverse determinations.

How long does the UR process take?
After the plan receives all the information it needs to make a decision, it has to let you or your representative, (your representative can be your HCP), and your HCP know the plan’s decision:

Within 1 business day by phone and then in writing if it’s for services that you are already receiving and you or your HCP feels you need to continue (for example, more days in the hospital). When your plan lets you and your HCP know, the plan must tell both of you how many more services the plan approved, if any, (for instance, the number of added days in the hospital), the new total of services approved, the date these services begin and the next date that the plan will review whether these services continue to be medically necessary.

Within 3 business days, after the plan has received all necessary information and then in writing, if it concerns pre-approving a benefit or referral.

Within 30 days when it’s a decision about a benefit that you’ve already received: for example, your doctor did a procedure and the plan later decides it won’t pay for it because the UR decides it was not medically necessary.

If the plan doesn’t respond to the request in the time frames listed above, the plan will be considered to have denied the benefit, treatment or referral (an adverse determination) and you can immediately appeal this denial to the plan.

What happens in an Adverse Determination?

Your health plan’s decision to deny a benefit that you or your provider requested because the plan says it is not medically necessary is called an adverse determination. In adverse determinations the plan must send you a Notice of Denial. It must be in writing and include:

The reasons with the medical explanation, if any;

That you and your representative can request the clinical review criteria (medical standards) the plan used to make that decision;

How to appeal the decision and what information the plan needs for your appeal;

Your right to an external appeal.

Reconsideration of Adverse Determinations

If the UR staff at the plan made their decision without talking it over with the HCP who recommended your benefit or referral, the HCP can request that the plan reconsider
its decision:

Within 1 business day, the HCP who requested the benefit, treatment or referral and the UR person who made the original decision must discuss it. After the discussion, the UR person must notify the HCP of his/her decision.

You and your provider have the right to appeal an Adverse Determination.

All appeals will be handled by a plan staff person who did not make the original decision. If a doctor requested the benefit that was denied, the plan staff person who handles your appeal must be a doctor in the same or similar specialty. There are two kinds of appeals, expedited and standard.

How long does the Expedited Appeal process take?

An appeal can be decided quickly where the request is for continued or extended services (for example, more days in the hospital) or for more services for someone having ongoing treatment (for example, more rehabilitation therapy after a stroke).

An expedited appeal is also allowed in any situation where your provider believes it is necessary. But there are no expedited appeals for benefits that you have already received.

Within 1 business day after the UR people at your plan receive an expedited appeal, you or your representative and your HCP must be able to get in touch with a UR staff person who has the qualifications described above.

Within 2 business days, after the plan receives all necessary information, a decision must be made.

If, after an expedited appeal, the plan makes an adverse determination and denies what you or your HCP wanted, you can request an external appeal.

How long will a Standard Appeal take?

You have at least 45 days after the plan notifies you of an adverse determination and you’ve been given all the information you need to file an appeal. It is up to the plan to decide if you have to appeal in writing or by phone.

Within 15 days after you file your appeal, the plan has to send you a written acknowledgment of the appeal.

Within 60 days, after the plan receives all the necessary information, the plan must make a decision.

Within 2 business days after making their decision, the plan must let you, your representative, and your HCP (when that’s appropriate) know their decision.

The notice of the decision about either your expedited or standard appeal must include the reasons and, when an adverse determination is upheld, the medical explanation. It must also include your right to file an external appeal, how to request an external appeal from the State Insurance Dept., including the forms you and your provider must submit to the Insurance Department, the Insurance Department’s toll-free number, a description of the external appeal process, including how long the process will take.

If the plan fails to respond to your appeal within the time frames listed above, the plan’s decision to deny coverage is reversed.

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