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MP CareSolutions (MPCS)

2016 Policies & Procedures

For Management of

Medicaid Managed Care (MMC), Child Health Plus

(CHP), Essential Plan (EP) Contracts

Utilization Management

&

Appeals & Grievances (Advocacy)

1 MPCS Policies & Procedures

MMC, CHP, and EP Contracts Utilization Management Appeals & Grievances (Advocacy)

Table of Contents While holding the control key, click on the subject from the left column you wish to access

Policy Definitions

2

MPCS 01- UM Program Review

5

MPCS 02- UM Determination & Notification Requirements

7

MPCS 03- UM Review Criteria & Criteria Availability

21

MPCS 04- Utilization Review Process

23

MPCS 05- UM Staff Availability

30

MPCS 06- UM Behavioral Health

31

MPCS 08- Appeals, Grievances, Fair Hearing

32

MPCS 09- UM Inter-Rater Reliability

41

MPCS 10- Collection & Documentation of Relevant Information for UR Determinations

48

MPCS 11-Utilization Management Personnel

52

MPCS 12-Confidentiality

58

MPCS 13- Technology Evaluation & Medical Policy for UR Determinations

61

MPCS 14- Continuity of Care

63

MPCS 15- Emergency Services

65

MPCS 16- UM Out of Network Requests

66

MPCS 19- UM Quality Improvement Initiatives

70

MPCS 20- UM Clinical Peer Reviewers

74

MPCS 21- UM Pharmacy Management

76



Utilization Management Policy Definitions

Action Administrative or utilization review determinations that include the

following:

Denial or limited authorization of a service, including the type

or level of service.

Reduction, suspension, or termination of a previously

authorized service.

Denial in whole or part, of payment for a service.

Failure to provide review decisions in a timely manner.

Failure to act within the timeframes for resolution and

notification of determinations regarding complaints, action

appeals, and complaint appeals.

Adverse Determination

A denial of a service request or an approval of a service request in an

amount, duration, or scope that is less than requested.

Appeal

A request to change a previous decision made by the contractor from

either a medical necessity determination or an

experimental/investigational action.

Authorization Request

A request by an Enrollee, or a provider on the Enrollee’s behalf, to the

contractor for the provision of a service, including a request for a

referral or for a non-covered service.

Child Health Plus (CHP)

A social health care program for children between ages 0-19 who meet

specific eligibility requirements.

Clinical Peer Reviewer

A physician who possesses a current, valid, and unrestricted license to

practice medicine. A clinical peer reviewer may also be a health care

professional other than a licensed physician who, where applicable,

possesses a current and valid non-restricted license, certification, or

registration, or where no provision for a license, certificate, or

registration exists, is credentialed by the national accrediting body

appropriate to the profession and is in the same or similar

profession/specialty as the health practitioner who typically manages the

medical condition.

Concurrent Review

The process of evaluating a request for continued services during an

episode of care that was previously authorized. Concurrent reviews are

performed on both inpatient and outpatient services .

Denial

An inpatient or outpatient pre-service, concurrent, post-service, or

retrospective service request that has not been approved due to lack of

medical necessity and/or benefit coverage. Partial approvals are also

considered to be denials.

Disabling and Degenerative

Disease or Condition

A disease or condition that requires ongoing specialized treatment over

an extended period of time in order to stabilize and/or slow the

progression of symptoms and the loss of bodily and/or vital organ

function. Examples of such a disease or condition are Multiple Sclerosis

and Cerebral Palsy.

Elective A planned service or procedure which is performed by choice.

Emergent Care Treatment of a medical or behavioral condition, that manifests itself by

acute symptoms of sufficient severity, including severe pain, such

that a prudent layperson, possessing an average knowledge of

medicine and health, could reasonably expect the absence of immediate

medical attention to result in placing the health of the person afflicted

with such condition in serious jeopardy, or in the case of a behavioral

condition, placing the health of such person or others in serious



jeopardy, serious impairment to such person's bodily functions,

serious dysfunction of any bodily organ or part of such person, serious

disfigurement of such person, or a condition described in clause (i),

(ii) or (iii) of section 1867(e)(1)(A) of the Social Security Act.

Emergency/Urgent Condition A medical or behavioral condition, that manifests itself by acute

symptoms of sufficient severity, including severe pain, such that a

prudent layperson, possessing an average knowledge of medicine and

health, could reasonably expect the absence of immediate medical

attention to result in placing the health of the person afflicted with

such condition in serious jeopardy, or in the case of a behavioral

condition, placing the health of such person or others in serious

jeopardy, serious impairment to such person's bodily functions,

serious dysfunction of any bodily organ or part of such person, serious

disfigurement of such person, or a condition described in clause (i),

(ii) or (iii) of section 1867(e)(1)(A) of the Social Security Act.

Expedited Appeal A request to change an adverse determination as fast as the Enrollee’s

condition requires, within two (2) business days of receipt of necessary

information, and no later than three (3) business days of the date of the

receipt of the appeal.

Expedited/Urgent Review A review that must be conducted when the contractor determines or the

provider indicates that a delay would seriously jeopardize an Enrollee’s

life or health or ability to attain, maintain, or regain maximum function.

The Enrollee may request expedited review of a prior authorization

request or concurrent review request. If the contractor denies the

Enrollee’s request for expedited review, the contractor must handle the

request under standard review timeframes .

Grievance Procedures

Right to file a complaint regarding any dispute between the Contractor

and an Enrollee.

In-Network Services Services with a contracted provider.

Life Threatening

Disease/Condition

A disease or condition that requires specialized treatment over a period

of time for the purposes of stabilization of symptoms and prevention of

further loss of bodily and/or vital organ function and/or loss of life.

Examples of such a disease or condition are cancer and organ

transplants.

Medical Director A physician who possesses a current, valid, and unrestricted license to

practice medicine whose responsibility is to provide guidance and

decision making during the utilization review process. The Medical

Director must be board-certified, preferably in a primary care specialty,

and have at least five years of practice experience. In situations that

require specialty expertise outside of the Medical Director’s own clinical

field, the Medical Director may rely on the expertise of a clinical peer

reviewer for that particular specialty field.

Medicaid Managed Care Social health care programs for families and individuals with low

income and resources who meet specific eligibility requirements.

Medical Necessity

Per the NYS Medicaid Managed Care Model Contract, medical

necessity is defined as health care and services that are necessary to

prevent, diagnose, manage or treat conditions in the person that cause

acute suffering, endanger life, result in illness or infirmity, interfere with

such person's capacity for normal activity, or threaten some significant

handicap. For children and youth, medically necessary means health

care and services that are necessary to promote normal growth and

development and prevent, diagnose, treat, ameliorate or palliate the

effects of a physical, mental, behavioral, genetic, or congenital

condition, injury or disability

Out-of-Network (OON) Services Services by a non-contracted provider.

Partial Denial When a part of a, but not a total, service request is approved.

Post-Service Appeal A request to change an adverse determination on utilization review



determination that was made after the services were rendered.

Post-Service Review Post-service (or retrospective) review is the process of evaluating a

request for services that have already been rendered. Post-service

reviews are performed on both inpatient and outpatient services .

Pre-service Appeal

A request to change an adverse determination on utilization review

determination that was made before the services were rendered.

Pre-Service Review

The process of evaluating a request for services before they are

rendered. Pre-service reviews are performed on both inpatient and

outpatient services .

Prior Authorization

Also known as pre-authorization or prior approval, services for which

approval must first be obtained through the utilization review process

before rendering. Lists of services that require pre-authorization are

distributed bi-annually and are available on the client Health Plan’s

internet for reference.

Rare Disease A life threatening or disabling condition that is currently, or has been the

subject of research by the National Institutes of Health Rare Disease

Clinical Research Network or affects fewer than 200,000 U.S. residents

per year.

(rarediseases.info.nih.gov)

Reconsideration

If the UR agent did not attempt to discuss an adverse determination with

the provider, the provider has the right to ask for a reconsideration of the

adverse determination, and the UR agent must respond within one

business day for pre-service and concurrent reviews.

Specialty Care Center A center accredited or designated by an agency of the s tate or federal

government or by a voluntary national health organization as having

special expertise in treating the condition or disease for which it has

been accredited or designated.

Utilization Review Agent Any company, organization, or other entity performing utilization

review, any insurer subject to Article 32 or 43 of the Insurance Law and

any independent utilization review agent performing utilization review

under a contract with such insurer, which shall be subject to Article 49

of the NYS Insurance law, with the exception of the following:

An agency of the federal government.

An agent acting on behalf of the federal government, but only

to the extent that the agency is providing services to the federal

government.

An agent acting on behalf of the state or local government for

services provided pursuant to Title IX of the federal Social

Security Act.

A hospital’s internal quality assurance program, except if

associated with a health care financing mechanism.



MPCS 01

UM Program Review

Policy Statement

The Utilization Management (UM) program is reviewed at least on an annual basis by the MPCS ’ UM Quality Committee. The UM Quality Committee is responsible for advising

upon all UM quality activities, and monitoring that said activities are in fulfillment of UM quality requirements set forth by state, federal, & accreditation bodies so as to ensure the

highest quality of UM services are being delivered that enable members to stay healthy, get better, manage chronic illnesses and/or disabilities, and maintain/improve their quality of life. Quality of care refers to quality and access to culturally competent physical health

care, primary care, behavioral health care (which is focused on recovery, resiliency, and rehabilitation), pharmacy care, and community and facility based long term support services

(as applicable to what MPCS is delegated to manage), and continuity and coordination of such care across all service settings, including transitional care.

The UM Quality Committee is a subcommittee of the Board of Directors, and is primarily comprised of practicing physicians, specialists, and MPCS ’ clinical management.

Committee members are appointed by the chair of the Quality Committee unless otherwise specified. MPCS ’ Chief Medical Office (CMO), a board-certified senior physician with a current, valid, and unrestricted license, trained in the principles and practices of

utilization review, is accountable for the direct oversight of UM program and its components and chairs the Quality Committee. The CMO holds primary accountability for

oversight of the UM program and its entirety. It is expected that contractors, agents, or vendors who conduct utilization review on behalf of MPCS also appoint a medical director, a board-certified senior physician with a current, valid, and unrestricted license, trained in

the principles and practices of utilization review, to provide supervision and oversight of the utilization review process. However, the UR agent may appoint a clinical director

within the scope of practice of the UR being performed is for a discrete category of health care service. A behavioral health practitioner (physician or PhD level) also serve as a committee member and is involved with the implementation of the behavioral healthcare

aspects of the UM program.

The UM Quality committee meets at least on a quarterly basis, and makes recommendations for improvements based on outcomes of quality measures, and continuously monitors for progress. Meetings are structured by an agenda. Meeting

minutes provide support of committee activities. This activity is reported to clients that MPCS provides delegated UM services for. To the extent that MPCS is accredited by the

National Committee for Quality Assurance (NCQA), issues identified during the NCQA accreditation process must be reported to the New York State Department of Health (NYSDOH) within thirty (30) calendar days of being notified of any issues, or on the

earliest date permitted by the NCQA, whichever is earliest.



Procedure

During the first quarter of the calendar year, the UM Program Description and

Policies & Procedures are reviewed for necessary updates to the program structure, responsibilities, annual goals & objectives, and utilization review criteria &

procedures. Updates are then submitted to the UM Quality Committee for review, feedback, and approval no later than the second quarter of the calendar year.

The UM dashboard is a living document that serves as a tool for reporting upon overall quality, compliance, and performance of the UM program throughout the

year. Quality, compliance, and performance measures on the dashboard include utilization review (UR) volume & time frames data, UR trends, provider/member satisfaction surveys, outcome of quarterly inter-rater reliability audits, annual goals

& objectives, and progress towards meeting annual goals & objectives. These measures are reported to the UM Quality Committee at least quarterly for review

and feedback on strengths and recommendations for improvement.

Tracking Mechanism

The Chief Medical Officer, in collaboration with UM management, is responsible for ensuring that the UM program is reviewed at least on an annual basis, and findings are

presented to the UM Quality Committee for review, feedback, and approval. Oversight

The Chief Medical Officer, in collaboration with UM management, is responsible for oversight of this policy.



MPCS 02

UM Determination & Notification Requirements

Policy Statement

Utilization review decisions on approved and denied concurrent, prospective, retrospective, and urgent review types, and written and verbal notice of such decisions to enrollees (or

designees) and their health care provider(s), must be made within time frames set forth by state, federal, & accreditation bodies outlined in this policy, or as fast as the enrollee’s

condition requires. Where time frames differ, MPCS follows the most stringent time frames standards.

Procedure

1. Decision Timeliness

Refer to Tables 1 & 2 below to determine the decision and written & verbal notification time frame requirements by product, review type, and review priority. Once

a utilization review determination is made within required time frames, proceed to step # 2 for instructions on generating a timely and compliant verbal notification. UR

determinations not made within these time frames will automatically result in an adverse determination subject to appeal, and notice of action must be sent to the member on the date time frames expire. MPCS does not deny requests for expedited

review.



Table 1

Child Health Plus & Essential Plan

Review Type &

Priority

Decision & Notification Time Frame Standards

(if all information is available at the time of initial

request)


(if additional information is required at the time the initial request

is received)

Pre-Service

(Prospective)

Non-Urgent

Decision, verbal notification, and written notification to

member (or designee) & provider(s) must be completed as fast as the enrollee’s condition requires or within 3

business days. If a member requests an expedited review

and the Health Plan denies the request, the Health Plan

must send a notice stating that it has denied the expedited

request and will review the case within standard timeframes. Notice to the enrollee that the enrollee’s

request for an expedited review has been denied shall

include that the request will be reviewed under standard

timeframes, including a description of the timeframes, and

a statement that oral interpretation and alternate formats of written material for enrollees with special needs are

available and how to access the alternate formats.

Within 3 business days of the original request, send a written request to

the member (or designee) & provider(s) for the specific information

needed. The request must specify the time period given to the member

(or designee) & provider(s) to furnish the needed information. The member (or designee) & provider(s) must be given at least 45 calendar

days to provide the information. Once the information is received, the

decision, verbal and written notification must be made within 3 business

days. If no information or incomplete information is received by the end

of the specified time period given, the decision, verbal and written notification must be made within 3 business days using whatever

information has already been received.

Pre-Service

(Prospective) Urgent

(Expedited)

Decision, verbal notification and written notification to

member (or designee) & provider(s) must be completed as fast as the enrollee’s condition requires, or within 72 hours.

Within 24 hours of the original request, send a written request to the member

(or designee) & provider(s) for the specific information needed. The request must specify the time period given to the member (or designee) & provider(s)

to provide the needed information. The member (or designee) and

provider(s) must be given at least 48 hours to provide the information. Once

the information is received, the decision, verbal and written notification must

be made within 48 hours. If no information or incomplete information is received by the end of the specified time period, the decision must be made

within 48 hours of the end of the specified time period given using whatever




Concurrent

Non-Urgent


member (or designee) & provider(s) must be completed as fast as the enrollee’s condition requires or within 1business

day. Notification of continued or extended services must

include the number of extended services approved, the new

total of approved services, the date of onset of services and the next review date. If a member requests an expedited

review and the Health Plan denies the request, the Health

Plan must send a notice stating that it has denied the

expedited request and will review the case within standard

timeframes. Notice to the enrollee that the enrollee’s request for an expedited review has been denied shall

include that the request will be reviewed under standard

timeframes, including a description of the timeframes, and

a statement that oral interpretation and alternate formats of

written material for enrollees with special needs are available and how to access the alternate formats.

Within 1 business day of the original request, send a written request to the

member (or designee) & provider(s) for the specific information needed. The

request must specify the time period given to the member (or designee) & provider(s) to provide the needed information. The member (or designee) &

provider(s) must be given at least 45 calendar days to provide the information.

Once the information is received, the decision, verbal and written notification

must be made within 1 business day. If no information or incomplete

information is received by the end of the specified time period given, the decision, verbal and written notification must be made within 1 business day

using whatever information has already been received.

Concurrent

Urgent


member (or designee) & provider(s) must be completed as fast as the enrollee’s condition requires, or within 24 hours.

Notification of continued or extended services must include the number of extended services approved, the new total of

approved services, the date of onset of services and the

next review date.

Within 24 hours of the original request, send a written request to the member

(or designee) & provider(s) for the specific information needed. The request must specify the time period given to the member (or designee) & provider(s)

to provide the needed information. The member (or designee) & provider(s)

must be given at least 48 hours to provide the information. Once the

information is received, the decision, verbal and written notification must be

made within 24 hours. If no information or incomplete information is received by the end of the specified time period, the decision must be made

within 24 hours of the end of the specified time period given using whatever


Post-Service

(Retrospective)

Decision and written notification to member (or designee),

& provider(s) must be completed within 30 calendar days of receipt of necessary information. No verbal notification

is required on post- service decisions.

Within 30 calendar days of the original request, send a written request to the

member (or designee) & provider(s) for the specific information needed The request must specify the time period given to the member (or designee) &

provider(s) to provide the needed information. The member (or designee) &

provider(s) must be given at least 45 calendar days to provide the

information. Once the information is received, the decision and written

notification must be made within 15 calendar days. No verbal notification is required on post-service decisions. If no information or incomplete

information is received by the end of the specified time period given, the

decision and written notification must be made within 15 calendar days using

whatever information has already been received. Reconsideration

of Adverse Determination

(for Prospective

& Concurrent

requests only)


member (or designee) & and provider(s) must be made as fast as the enrollee’s condition requires, or within 1

business day of request for reconsideration.

N/A



Table 2

Medicaid Managed Care

Review Type

& Priority

Decision & Notification Time Frame

Standards

(if all information is available at the time

the initial request is received)


(if additional information is required at the time the initial request is received)

Pre-Service

(Prospective)

Non-Urgent

Decision, verbal notification, and written

notification to member(or designee) & and

provider(s) must be completed as fast as the enrollee’s condition requires, or within 3

business days of the receipt of all necessary

information, but no later than 14 calendar days

after receipt of original request. Expedited

review of a service authorization request must be conducted when the MCO determines or the

provider indicates that a delay would seriously

jeopardize the enrollee’s life or health or

ability to attain, maintain, or regain maximum

function. If a member requests an expedited review and the Health Plan denies the request,

the Health Plan must send a notice stating that

it has denied the expedited request and will

review the case. . Notice to the enrollee that

the enrollee’s request for an expedited review has been denied shall include that the request

will be reviewed under standard timeframes,

including a description of the timeframes, and

a statement that oral interpretation and

alternate formats of written material for enrollees with special needs are available and

how to access the alternate formats.

Send a written request to the member (or designee) & provider(s) for the specific

information needed. If the Health Plan does not receive the information in time to make a

determination within 14 calendar days of original request, and it is in the member’s best

interest to have an extension, the Health Plan must send a notice of extension. The

member (or designee) or the provider(s) may also request an extension. Once the information is received, the decision, verbal and written notification must be made within

3 business days of the receipt of the necessary information or no later than the date the

extension expires, whichever is shorter. If no information or incomplete information is

received by the end of the specified time period given, the decision, verbal and written

notification must be made no later than the date the extension expires using whatever information has already been received. The notice of extension must specify the reason for

the extension, an explanation of how the delay is in the best interest of the member, the

additional information the Health Plan needs to make the determination, the right of the

member to file a complaint regarding the extension, the process and timeframes for filing a

complaint, the right of the member to designate a representative to file a complaint and the right of the enrollee to contact the New York State Department of Health regarding their

complaint. Notice of a determination in the extension period must be made verbally and in

writing as fast as the member’s condition requires and within 3 business days after receipt

of necessary information, but no later than the date the extension requires.

Pre-Service (Prospective)

Urgent

(Expedited)

Decision, verbal notification, and written notification to member (or designee) &

and provider(s) must be completed as fast as the enrollee’s condition requires, or within 1 business day of the receipt of

all necessary information but never more

than 3 business days from the date of the

request.

Send a written request to the member(or designee) & provider(s) for the specific Information needed. If the Health Plan does not receive the information in time to make a

determination within 3 business days of original request, and it is in the member’s best interest to have a 14 business day extension, the Health Plan must send a notice of

extension. The member (or designee) or provider(s) may also request an extension. Once

the information is received, the decision, verbal and written notification must be made

within 1 business day of the receipt of the necessary information or no later than the date

the extension expires, whichever is shorter. If no information or incomplete information is received by the end of the specified time period given, the decision, verbal and written

notification must be made within 3 business days of the date of the original request or no

later than the date the extension expires using whatever information has already been

received. The notice of extension must specify the reason for the extension, an explanation

of how the delay is in the best interest of the member, the additional information the Health Plan needs to make the determination, the right of the member to file a complaint

regarding the extension, the process and timeframes for filing a complaint, the right of the

member to designate a representative to file a complaint and the right of the enrollee to

contact the New York State Department of Health regarding their complaint. Notice of a

determination in the extension period must be made verbally and in writing as fast as the member’s condition requires and within 1 business day after receipt of necessary

information, but no later than the date the extension requires.



Concurrent

Non-Urgent


notification to member (or designee) & and


business day of the receipt of all necessary

information but never more than 14 calendar days from the date of the request. Notification

of continued or extended services must include

the number of extended services approved, the

new total of approved services, the date of

onset of services and the next review date. Expedited review of a service authorization

request must be conducted when the MCO

determines or the provider indicates that a

delay would seriously jeopardize the enrollee’s

life or health or ability to attain, maintain, or regain maximum function. If a member

requests an expedited review and the Health

Plan denies the request, the Health Plan must

send a notice stating that it has denied the

expedited request and will review the case within standard timeframes. Notice to the

enrollee that the enrollee’s request for an

expedited review has been denied shall include

that the request will be reviewed under

standard timeframes, including a description of the timeframes, and a statement that oral

interpretation and alternate formats of written

material for enrollees with special needs are

available and how to access the alternate

formats.

Send a written request to the member (or designee) & provider(s) for the specific

information needed. If the Health Plan does not receive the information in time to make a

determination within 14 calendar days of original request, and it is in the member’s best interest to have a 14 calendar day extension, the Health Plan must send a notice of

extension. The member (or designee) & designee or the provider(s) may also request an

extension. Once the information is received, the decision, verbal and written notification

must be made within 1 business day of the receipt of the necessary information or no later

than the date the extension expires, whichever is shorter. If no information or incomplete information is received by the end of the specified time period given, the decision, verbal

and written notification must be made within 14 calendar days of the date of the original

request or no later than the date the extension expires using whatever information has

already been received. The notice of extension must specify the reason for the extension,

an explanation of how the delay is in the best interest of the member, the additional information the Health Plan needs to make the determination, the right of the member to

file a complaint regarding the extension, the process and timeframes for filing a complaint,

the right of the member to designate a representative to file a complaint and the right of

the enrollee to contact the New York State Department of Health regarding their

complaint. Notice of a determination in the extension period must be made verbally and in writing as fast as the member’s condition requires and within 1 business day after receipt

of necessary information, but no later than the date the extension requires.

Concurrent

Urgent




business day of the receipt of all necessary

information but never more than 3 business days from the date of the request. Notification

of continued or extended services must include

the number of extended services approved, the

new total of approved services, the date of

onset of services and the next review date.

Send a written request to the member/provider for the specific Information needed. If the Health Plan does not receive the information in time to make

a determination within 3 business days of original request, and it is in the member’s

best interest to have a 14 calendar day extension, the Health Plan must send a notice of

extension. The member (or designee) or provider(s) may also request an extension. Once the information is received, the decision, verbal and written notification must be

made within 1 business day of the receipt of the necessary information or no later than

the date the extension expires, whichever is shorter. If no information or incomplete

information is received by the end of the specified time period given, the decision,

verbal and written notification must be made within 3 business days of the date of the original request or no later than the date the extension expires using whatever

information has already been received. The notice of extension must specify the reason

for the extension, an explanation of how the delay is in the best interest of the member,

the additional information the Health Plan needs to make the determination, the right of

the member to file a complaint regarding the extension, the process and timeframes for filing a complaint, the right of the member to designate a representative to file a

complaint and the right of the enrollee to contact the New York State Department of

Health regarding their complaint. Notice of a determination in the extension period

must be made verbally and in writing as fast as the member’s condition requires and

within 1 business day after receipt of necessary information, but no later than the date the extension requires.

Post-Service

(Retrospective)

Decision and written notification to member

(or designee), & provider (s) must be completed within 30 calendar days of receipt

of necessary information. No verbal

notification is required on post- service

decisions.

Within 30 calendar days of the original request, send a written request to the member (or

designee) & provider(s) for the specific information needed. The request must specify the time period given to the member (or designee) & provider(s) to provide the needed

information. Once the information is received, the decision and written notification must

be made within 5 business days or no later than the date the extension expires using

whatever information has already been received. If request is denied, written notification

must be sent on the date of payment denial.



Reconsideration

of Adverse

Determination (for Prospective

& Concurrent

requests only)



provider(s) must be made as fast as the enrollee’s condition requires, or within 1

business day of request for reconsideration.

N/A

2. Verbal Notice of Determination to Provider & Member

UM personnel are required to verbally notify members and appropriate providers of utilization review determination within required time frames. Refer to Table 4 for all parties who must receive a verbal notice of UM decisions per review type and priority

within the time frames specified in Tables 1 & 2. Once compliant and timely verbal notices are provided to all relevant parties, proceed to step # 3 for instructions on

generating timely and compliant written notifications. a. Provider Verbal Notice

When calling providers to give notification, at least one attempt is made. Document if the provider could not be reached due to no answer, no secure voice mail

available, or a busy signal using standard UM documentation protocol. If there is no phone number on file, search local directories and document the attempt.

If the call is answered, UM staff are required to identify themselves by their name, title, and organization. PHI may be communicated over an outbound or inbound

telephone call to a provider so as long as the recipient has been authenticated, the recipient has the authority to receive PHI, and the disclosure meets the minimum necessary requirements, and the disclosure meets the minimum necessary

requirements. If provider is not available, do not leave a message on an answering machine containing PHI. UM staff will leave a message with their name, title, and

organization from which they are calling, a call back number, and a brief statement that the call involves a utilization review decision. See PPM titled HIPPA- Disclosure of PHI by Phone about PHI disclosure or click on the following link:

http://policytech/dotNet/documents/?docid=2242&mode=view

UM personnel are available during business hours (8:00am-4:30 pm, Monday through Friday, excluding holidays) to answer questions regarding UM decisions, patient care, and the UM program by calling 1 (800) 683-3781 or by any direct call

back numbers given to providers by UM staff. Local and toll free telephone numbers are readily displayed on the member’s ID card, are published on the client

helath plan’s website, and are also provided in written UM determination notices. UM personnel are also available after hours in an on-call capacity at the above listed contact number for issues related to urgent UM requests or appeals. Toll free fax

numbers are published on the health plan’s website and are provided in written UM determination notices. MPCS also offers TDD/TTY services for deaf, hard of

hearing, or speech impaired members. These numbers are readily displayed on the health plan’s website and are also contained in written UM determination notices. Language assistance/interpretation is also available for members. Detailed

procedures for using TDD/TTY and language assistance services are located on the MPCS ’ intranet for UM staff.




MPCS customer service staff follow specific protocols for transferring members, providers, or prospective members who request to speak directly to the UM

department. Refer to the PPM titled UM Procedure-Triaging Calls to UM or click on the following link to access: http://policytech/dotNet/documents/?docid=2625&mode=view

Callers also have the option of leaving a confidential voicemail message with UM

personnel either during or after business hours. These calls are returned promptly

the same day or the next business day. UM staff are required to identify themselves by their name, title, and organization when initiating or returning calls. UM personnel adhere to all applicable minimally necessary disclosure policies and caller

authentication requirements outlined in HIPAA Privacy and Security Regulations during inbound and outbound calls.

Once the ability to disclose has been determined, inform the provider of the review outcome, total of denied services and from & to dates of such. Inform the provider

that written notice will be sent of the decision as well. Document the provider notification in its entirety using standard UM documentation protocol. Verbal

adverse determination notices to providers must include a rationale for the denial, a reference to the criteria on which the denial was based, an explanation of the reviewing physician’s decision when applicable, an offer to speak to the reviewing

physician regarding the decision when applicable, and instructions for appealing or grieving the determination that includes toll free telephone numbers. Also advise

the provider that a written notice of the decision will be sent.

In the event that a utilization review agent renders an adverse determination without

attempting to discuss such matter with the member’s health care provider who specifically recommended the health care service, procedure or treatment under

review, such health care provider shall have the opportunity to request a reconsideration of the adverse determination. Except in cases of retrospective reviews, such reconsideration shall occur within one business day of receipt of the

request and shall be conducted by the member’s health care provider and the physician reviewer making the initial determination or a designated physician

reviewer if the original reviewer is unavailable. In the event that the adverse determination is upheld after reconsideration, notice shall be provided pursuant to the verbal and written notice requirements outlined in this policy. The member is

still entitled to initial an appeal from an adverse determination regardless of the reconsideration process.

Providers may also request a phone consultation with the physician (or another designated physician reviewer if the original reviewer is unavailable) involved in

making any adverse UM determination. Phone consultations have no associated statutory timeframe.

To initiate and reconsideration or a consultation with the reviewing physician, the requesting provider may contact MPCS using the contact information noted above

and outlined in policy titled MPCS 05- UM Staff Availability.




The utilization reviewer will then schedule a conference call for the reviewing

physician (or designee) and requesting provider to discuss the denied case. The case is then prepared for and sent back to the reviewing physician. Once the case is

discussed and a decision is made, the reviewing physician documents the outcome of the discussion in the designated software application following standard UM documentation protocol. The case is then sent back to the utilization reviewer, who

completes the case by issuing verbal and written notices of the decision as appropriate, and in accordance to required timeframes as outlined in policy titled

MPCS 02- UM Determination & Notification Requirements.

In the event that the adverse determination is upheld after reconsideration or

consultation with the reviewing physician, the utilization review agent shall provide written and verbal notice of the adverse determination as outlined in this policy,

which includes nothing in this section shall preclude the member from initiating an appeal from an adverse determination.

Appeal procedures apply to adverse medical necessity and experimental or investigational determinations. Grievance (or complaint) procedures apply to any

aspect of services rendered by MPCS that does not pertain to an adverse medical necessity determination, or an experimental or investigational determination. Examples of intangible complaints include (but are not limited to) dissatisfaction

with treatment received from MPCS , its practitioners, or benefit administrators, quality of care issues, access to care issues, alleged violation of privacy practices

and policies, and fraud and abuse. Members, their authorized designee, or their health care provider (in connection

with retrospective determinations) may file a standard or expedited appeal or grievance by contacting MPCS at the phone number listed on the adverse

determination letter, at the phone number listed on the member’s ID card or @ 1 (800) 683-3781, or in person/ writing to 1120 Pittsford-Victor Road, Pittsford, NY, 14534. A member may also may file an appeal even if they have already received

the service. Appeal proceedings can be requested after business hours, on weekends, or on holidays by leaving a message at the telephone numbers listed

above. A representative will respond to the member’s request on the next business day. See policy titled MPCS 08- Appeals, Grievances & Fair Hearing for complete information on regulatory procedures and requirements on member & provider

appeals & grievances.

b. Member Verbal Notice When calling members to provide notification, at least two attempts are made within required time frames outlined in policy titled MPCS 02- UM Determination and

Notification Requirement if the member cannot be reached during the initial attempt due to no answer, no secure voice mail available, or a busy signal. If there is no

phone number on file to initiate the first attempt, search local directories and/or contact the local department of social services for this information, and document such efforts following standard UM documentation protocols.



Notifications can be given to members 12 years of age or older, except in cases that

include HIV/AIDS, Mental Health, Substance Abuse, Abortion, STD, or Genetic Testing, as a specialized authorization form is required to discuss such conditions

with someone other than the patient (see Table 5 below). If the call is answered, UM staff are required to identify themselves by their name,

title, and organization. If a confidential voice mail is reached, do not leave a message on an answering machine containing PHI. UM staff may refer to the

following template for leaving voicemails when contacting members: “ This is (insert UR reviewer’s name) from your health care company. Please call 1 (800) 683-3781or the toll- free customer service number listed on the back of your health

care ID card for additional information regarding this call”. See PPM titled HIPPA- Disclosure of PHI by Phone about PHI disclosure or click on the following

link: http://policytech/dotNet/documents/?docid=2242&mode=view

If the member is available, authenticate the call by verifying the member’s name, address, insurance ID, and date of birth. Member must be able to identify 2 of 3

items. If unable to authenticate, call ends. See PPM titled HIPAA --- Authentication of Caller for additional information about the call authentication process or click on the following link: http://policytech/dotNet/documents/?docid=1643&mode=view

If call is authenticated, inform the member of the review outcome, total of

approved/denied services, and from & to dates of such. For verbal notices involving adverse determinations, provide grievance or appeal rights & processes, and inform the member of their provider’s ability to speak with the reviewing physician

regarding the adverse decision. Appeal procedures apply to adverse medical necessity and experimental or investigational determinations. Grievance (or

complaint) procedures apply to any aspect of services rendered by MPCS that does not pertain to an adverse medical necessity determination, or an experimental or investigational determination. Examples of intangible complaints include (but are

not limited to) dissatisfaction with treatment received from MPCS , its practitioners, or benefit administrators, quality of care issues, access to care issues, alleged

violation of privacy practices and policies, and fraud and abuse. Members, their authorized designee, or their health care provider (in connection

with retrospective determinations) may file a standard or expedited appeal or grievance by contacting MPCS at the phone number listed on the adverse

determination letter, at the phone number listed on the member’s ID card or @ 1 (800) 683-3781, or in person/ writing to 1120 Pittsford-Victor Road, Pittsford, NY, 14534. A member may also may file an appeal even if they have already received

the service. Appeal proceedings can be requested after business hours, on weekends, or on holidays by leaving a message at the telephone numbers listed

above. A representative will respond to the member’s request on the next business day. See policy titled MPCS 08- Appeals, Grievances & Fair Hearing for complete information on regulatory procedures and requirements on member & provider

appeals & grievances.





Inform member that a letter will be sent of the decision as well. Document the

member notification in its entirety using standard UM documentation protocol.

Parent/designee of members less than 12 without the above noted conditions should be given verbal notice. Authenticate the call with parent/designee by verifying the member’s name, address, insurance ID, and date of birth. Parent/designee must be

able to identify 3 of 4 items to authenticate. If unable to authenticate, call ends. See PPM titled HIPAA --- Authentication of Caller for additional information about the

call authentication process or click on the following link: http://policytech/dotNet/documents/?docid=1643&mode=view.

If call is authenticated, inform the parent /designee of the review outcome, total of approved/denied services and from & to dates of such. For verbal notices involving

adverse determinations, provide grievance or appeal rights &processes, and inform the parent/designee that the member’s provider has the ability to speak with the reviewing physician regarding the adverse decision. Inform parent/designee that a

letter will be sent of the decision as well. Document the notification in its entirety using standard UM documentation protocol.

Table 4 Review Type & Review Priority Verbal Notice To:

Concurrent Urgent & Non-Urgent,

Pre-Service(Prospective) Urgent & Non-

Urgent,

Reconsideration

Member, Requesting Provider

Post-Service (Retrospective) N/A

Table 5 Protected

Diagnosis

Adult (18 yrs+) Child (<18 yrs)

HIV/AIDS Authorization Form Required No Authorization Form Required

Substance Abuse

Authorization Form Required Authorization Required even to

speak to parent or guardian.

Abortion

Authorization Form Required Authorization Required even to

speak to parent or guardian.**

STD Authorization Form Required Authorization Required even to

speak to parent or guardian. **

Genetic Testing

Authorization Form Required No Form Authorization Required

Mental Health Authorization Form Required No Authorization Form Required

**Exceptions must be made in certain situations where a minor is too young to write their name

(newborn with a STD, but cannot complete an authorization form). Exceptions should be few and

clearly documented.




3. Written Notice of Determination Provider & Member

UM personnel are required to notify members and appropriate providers in writing of utilization review determinations within required time frames. Refer to Table 6 for all

parties who must receive written determination notices (approval, denials, pends, and extensions) in accordance to review type, priority, and decision outcome.

Written notices are in easily understood language and are accessible to non-English speaking and visually impaired members.

Extension notices must include the reason for extension, an explanation of how the delay is in the best interest of the member, any additional information required from any source to

make the determination, the member’s right to file a complaint regarding the extension, the process for filing a complaint and the time frames with which the complaint determination

must be made, the member’s rights to designate a representative to file a complaint on the member’s behalf, the member’s right to submit a complaint to the NYSDOH, and the toll-free number for filing such a compliant.

All written adverse determination notices must specify the total of denied services and

from & to dates of such, the rationale for the denial, including a reference to the criteria on which the denial was based, a description of the actions to be taken, information on standard, expedited, and external appeal and grievance rights, instructions on how to access

such rights (which includes a toll-free number and address), an explanation that an expedited appeal can be requested if a delay would significant increase the risk to a

member’s health, the time frames for which all level of appeal and grievance determinations must be made, a description of what additional information, if any, must be obtained from any source in order to make an appeal determination, description of the

member’s right to contact the New York State Department of Health and/or New York State Insurance Department (which includes toll free telephone numbers), instructions for

obtaining a copy of the clinical criteria used in making the determination, a statement regarding the availability of the member’s health care provider to discuss the denial decision with the reviewing physician or other appropriate reviewer, instructions about

how the member can obtain information about the diagnosis or treatment code related to the case, information on fair hearing and aid to continue rights and instructions on how to

access these rights (for Medicaid Managed Care and Family Health Plus members), a statement that the notice is available in other languages and format for special needs and information on how to access these formats, and any additional information required to

render a decision on appeal. See Appendix A of this policy for an example of the notice of determination that is provided with initial adverse determination letters. See Appendix B of

this policy for an example of the fair hearing notice that is provided with initial adverse determination letters for Medicaid Managed Care and Family Health Plus members.

In addition to the above,

Action notices involving out-of-network services that are not materially different from an alternative services available from a participating providers must include a description of the alternative service available in-network and how to access the

alternative service or obtain authorization for the alternative services(if required by the contractor), notice of the required information that must be submitted when



filing an action appeal for the member to review the medical necessity of the

requested service, a statement that if the action appeal is upheld as not medically necessary, the member may be eligible for an external appeal, if the Plan will not

conduct a UR appeal in the absence of the information described in PHL 4904 (1-a), a statement that if the requested information for filing an action appeal is not provided, the appeal with be reviewed by the Plan, but the member will not be

eligible for an external appeal, a statement that if the action appeal is upheld as not medically necessary, the member will have four (4) months from the receipt of the

final adverse determination to request an external appeal, a statement that the member and the Plan may agree to waive the internal appeal process, and the member will have four (4) months to request an external appeal from the receipt of

the written notice, and a statement that if the member files an expedited action appeal for the review of medical necessity of the requested service, the member may

request an expedited external appeal at the same time, and a description of how to obtain an external appeal application.

Action notices involving restrictions on MMC and FHP members under the Plan’s restricted recipient program (RRP) must include the effective date of restriction, the

scope and type of restriction, the name, address, and phone number of the RRP provider(s) the enrollee is restricted to, and the right of the enrollee to change an

RRP provider.

Action notices involving personal care services for MMC members must include the

number of hours per day, number of hours per week, and the personal care services function (Level I/Level II), that were previously authorized (if any), that were

requested by the Enrollee or their designee (if so specified in the request) , that are authorized for the new authorization period (if any), and the original authorization period and the new authorization period, as applicable.

Action notices involving prescription medications denials specified in section10.32

(g) of the Medicaid Managed Care/Family Health Plus Model Contract must specify that the requested medication is provided when the prescriber demonstrates

that, in their reasonable professional judgment [either by consistency with U.S. Food and Drug Administration approved labeling or use supported in at least one of the Official Compendia as defined in federal law under the Social Security Act

§1927 (g)(1)(B)(i)], that the medication is medically necessary and warranted to treat the member, and whether the appeal is upheld because the necessary

information to complete the request was not provided (including a description of the information needed) prior to the review time frame expiring, or the prescriber’s reasonable professional judgment was not demonstrated prior to the review time

frame expiring.

Action notices on issues of medical necessity or experimental or investigational treatment must include a clear statement that the notice constitutes the initial

adverse determination and specific use of the terms “medical necessity” or “experimental/investigational”, a statement that the specific clinical review criterial relied upon in making the determination is available upon request, a statement that

the member may be eligible for external appeal, a statement that if the denial is



upheld on action appeal, the member will have four (4) months from receipt of the

final adverse determination to request an external appeal, a statement that the member and the contractor may agree to waive the internal appeal process, and the

member will have four (4) months to request an external appeal from receipt of written notice of that agreement, and a statement that if the member files an expedited action appeal, the member may request an expedited external appeal at the

same time, and a description of how to obtain a external appeal application.

Table 6

Decision Outcome, Review Type &

Review Priority

Primary

Recipient of

Written

Notice:

Carbon Copies of Written Notice

To:

Approval

Concurrent Urgent & Non-Urgent, Pre-

Service(Prospective) Urgent & Non-Urgent,

Post-Service (Retrospective)

Member Servicing Provider, Requesting

Provider*, PCP

Denial

Concurrent Urgent, Concurrent Non-

Urgent, Reconsideration on Concurrent

Review, Post Service (Retrospective)

Member PCP, Requesting Provider*,

Servicing Provider

Pre-Service(Prospective) Urgent & Non-

Urgent, Reconsideration on Prospective

Request

Member PCP & Requesting Provider *

Pend & Extension

Concurrent Urgent & Non-Urgent, Pre-

Service (Prospective) Urgent & Non-

Urgent, Post-Service (Retrospective)

Requesting

Provider *

PCP & Member

Key:

*Requesting- May also be the servicing provider or PCP. Do not send duplicate letters.

PCP-Primary Care Physician

Effective 7/1/14, revisions to Article 49 of the New York Public Health Law require plans to provide electronic transmission of written notice to providers to the extent practicable, and in a manner and form that is agreed upon by both parties. MPCS is obligated by law to offer one form of electronic notification, and currently we offer e-mail or fax. Providers can either accept this form of notification or wait for the mailed copy. The electronic notice, as well as verification that the written notice was transmitted is retained within the care management system. Instructions for uploading the verification can be found in sections a & b below.

a. Email Transmission

1. Identify the provider’s email address. 2. Generate the appropriate letter in accordance to normal protocol. 3. Once the letter is generated, save the letter to desktop using the member and event ID in

the following format: 200000000_MR123456 4. Using Microsoft Outlook, upload the letter to an email to the addressed provided. 5. Title the subject of the email in the following format:

UM Written Notice-200000000_MR123456 6. To ensure PHI is protected during the transmission process, refer to PPM titled Email

Encryption (or click on the link) for instructions on encrypting emails that contain PHI.

http://policytech/docview/?docid=3257

http://policytech/docview/?docid=3257



7. Add note to review in UM documentation system to support that decision letter was issued electronically.

8. Delete UM decision letter from desktop once sent to provider.

b. Fax Transmission 1. Identify the provider’s email address. 2. Generate the letter in accordance to normal protocol. 3. Once the letter is generated, save the letter to desktop using the member and event ID

in the following format: 200000000_MR123456 4. Using Microsoft Outlook, upload the letter to an email. In the To field, enter the

receiver of the fax in parenthesis, followed by the fax number using the following format: (Mary Smith) [email protected]. For local faxes, a 1 or area code is not required. Do not enter dashes.

5. Title the subject of the email in the following format: UM Written Notice-200000000_MR123456

6. Select Send. Do not select Encrypt & Send, or the fax will not transmit. 7. Add note to review in UM documentation system to support that decision letter was

issued electronically. Paste the fax receipt in note.

8. Delete UM decision letter from desktop once sent to provider.

Tracking Mechanism

UM staff use designated software systems to track the utilization review process in its entirety.

Oversight

The Chief Medical Officer, in collaboration with UM management, is responsible for

oversight of this policy.

mailto:[email protected]



MPCS 03

UM Review Criteria and Criteria Availability

Policy Statement

Clinical criteria used to make utilization review decisions are based on credible scientific evidence published in peer reviewed medical literature generally recognized by the medical

community. Guidelines take into account physician society recommendations, the views of the physicians practicing in relevant clinical areas, the needs of the members in consultation with participating providers, and other relevant factors to the extent practicable. New

and/or revised UM criteria is reviewed at least every 24 months (and as it becomes available) to ensure adherence to these standards. It is expected that contractors, agents, or

vendors who conduct utilization review on behalf of MPCS must also develop and maintain written clinical review criteria for use in and as part of the utilization review process.

UM personnel receive training on new and/or revised criteria once approved for use.

Criteria is made available to participating providers, non-participating providers, members, and eligible individuals via the client health plan’s bulletins, newsletters, and website.

Procedure

Sources of benefit and clinical necessity criteria used to make utilization review decisions

include, but are not limited to the following. Criteria is applied in a hierarchy fashion that begins with New York State (NYS) issued criteria. MPCS follows least restrictive criteria if no NYS issued criteria available.

NYS

Coverage Criteria & Guidelines

Used to make medically necessity and benefit

determinations. New and updated are released by the

state on a regular basis, and involve appropriate

practitioners and stakeholders in their policy

development.

InterQual Criteria

Nationally recognized, objective standards used for

determining clinical necessity. Under the guidance of

appropriate clinical professionals, these guidelines

are reviewed, updated, and reissued by McKesson on

an annual basis.

Corporate Medical Policies(CMP)

Plan-issued guidelines used to make utilization

review decisions. CMP are reviewed, updated and

modified annually by the Quality Committee.

Recommendations from the CMO, the Quality

Committee, clinical peer reviewers, and/or the

participating physicians may be utilized in the

development and evaluation of the criteria.

Criteria used to make UM decisions are accessible to network providers, members, and

prospective members upon request. UM criteria can be verbally requested by calling MPCS at 1 (800) 683-3781, or submitting a fax request to 1 (888) 273-8296. Requests may also be submitted in writing to MPCS , 1120 Pittsford-Victor Road, Pittsford, N.Y. 14534.



Upon receiving a request for criteria, MPCS staff will accommodate the request by

providing criteria verbally or in writing, whichever is preferred.

Tracking Mechanism & Oversight

MPCS ’ Chief Medical Officer, in collaboration with UM management, has oversight of this policy



MPCS 04

Utilization Review Process

Policy Statement

The utilization review process consists of accepting requests for, and making benefit and

clinical necessity determinations on, health care services for which the client health plan determines is subject to the utilization review process. Service requests may be inpatient or outpatient, prospective, concurrent, retrospective, urgent or non-urgent, and inclusive of

the review types outlined below. Out-of-network requests MPCS accepts requests for out-of-network services

from members (their designees) or their providers. See

policy titled MPCS 16- Out of Network Requests for

detailed instructions on the utilization review process.

Level of care determinations MPCS determines through the utilization review

process outlined in the Procedure section of this policy

that the level of care being requested or received is

appropriate to meet the member’s health care needs.

Experimental/investigational treatment MPCS accepts requests for experimental/investigational

treatment from members (their designees) or their

providers. An experimental/investigational services is

defined as one where there is insufficient information to

determine if the service is of proven benefit for a

particular diagnosis or for treatment of a particular

condition, one not generally recognized by the medical

community, as reflected in published, peer-reviewed

medical literature as effective or appropriate for a

particular diagnosis or for treatment of a particular

condition, or one not of proven safety for a person with a

particular diagnosis or a particular condition (i.e., which

is under evaluation in research studies to ascertain the

safety and effectiveness of the treatment on the well-

being of a person with the particular diagnosis or

condition). Said requests are subject to the utilization

review process outlined in the Procedure section of this

policy. All experimental/investigational requests require

physician review.

Specialty care providers & centers MPCS accepts requests for members with a life-

threatening or a degenerative and disabling condition or

disease, which requires prolonged specialized medical

care to receive a referral to an accredited or designated

specialty care providers & centers with expertise in

treating the life-threatening or degenerative and

disabling disease or condition, consistent with PHL §

4403(6)(d). These requests may be generated by the

member (or designee) or the member’s provider. Said

requests are subject to the utilization review process

outlined in the Procedure section of this policy.

Second opinions MPCS accepts requests for second opinions for

diagnosis of a condition, treatment, or surgical procedure

by a qualified physician or appropriate specialist,

including one affiliated with a specialty care center. In

the event that there are no provider within the network



with appropriate training and experience to provide a

second opinion, a referral to an appropriate non-

participating provider will be considered, and the cost of

obtaining such services will be covered by MPCS .

These requests may be generated by the member (or

designee) or the member’s provider. Said requests are

subject to the utilization review process outlined in the

Procedure section of this policy.

Standing referrals MPCS accepts requests for standing referrals for

members who require ongoing care from a specialist,

consistent with PHL § 4403(6)(b). A standing referral is

a request for a member to receive specified services

from a specialist without having to obtain a repeated

referral from their PCP. These requests may be

generated by the member (or designee) or the member’s

provider. Said requests are subject to the utilization

review process outlined in the Procedure section of this

policy.

Specialist as a coordinator of primary care MPCS accepts requests for members with life-

threatening or degenerative and disabling disease or

condition, which requires prolonged specialized medical

care, to receive a referral to a specialist, who will then

function as the coordinator of primary and specialty care

for that member, consistent with PHL § 4403(6)(c).

These requests may be generated by the member (or

designee) or the member’s provider. Said requests are

subject to the utilization review process outlined in the

Procedure section of this policy.

A continuation of existing relationships for

diagnosis and treatment of rare disorders

MPCS accepts requests for continuation of existing

relationships for diagnosis and treatment of rare

disorders. These requests may be generated by the

member (or designees) or the member’s provider. Said

requests are subject to the utilization review process

outlined in the Procedure section of this policy. See also

policy titled MPCS 14- Continuity of Care.

Any other services identified by the client

health plan as having referral, prior

authorization, or utilization review

requirements .

MPCS accepts prior authorization and referral requests

from members (or designees)or the member’s providers.

Said requests are subject to the utilization review

process outlined in the Procedure section of this policy.

A list of services that require pre-authorization are

distributed bi-annually and are available on the client

Health Plan’s internet for reference.

The above services are reviewed by staff comprised by medical directors (also known as physician reviewers), physician- level clinical peer reviewers, registered nurses, licensed

social workers, and licensed practical nurses with current, valid, and unrestricted licenses. Refer to policy titled MPCS 11-Utilization Management Personnel for full job descriptions

and reviewer accountabilities.

Procedure

1. UM staff follow standard review protocols and reference appropriate criteria for evaluating service requests that are subject to the UR process as noted above. Benefit



coverage is first assessed through internal systems and processes in accordance to New

York State (NYS) contracts and coverage guidelines. Utilization reviewers who are registered nurses, licensed master level social workers, or licensed practical nurses

trained in the principles and practices in utilization review may contractually deny cases (that are within their respective scopes of practice) as not meeting established benefit criteria; although involvement of physician reviewers may be considered in

instances where recommendation is made to approve services beyond the benefit limitation if it is in the best interest of the member.

2. If benefit coverage is met, all available and necessary relevant clinical information,

including medical records, are obtained prior to the review to enable the utilization

reviewer to make an appropriate determination regarding services requested. Information obtained for utilization review decisions come from many sources. The

amount and/or type of data required to make a utilization review determination depends on the circumstances of the case. Written and/or verbal information may be obtained from a member’s primary care physician, or any specialist, ancillary, or institutional

provider involved in the member’s care.

Collected information is then reviewed against established criteria and guidelines to make utilization review determinations. MPCS maintains procedures on data sources that may be gathered for UM decision making, and standards for documenting the

request, receipt, processing, and storing of such data. Data sources that may be gathered for UM decision making may include, but are not limited to office and/or

hospital records that may include a history of illness, psychosocial issues, diagnostic testing results, clinical exams, treatment plans, and progress notes, evaluations from and conversations with applicable health care providers, photographs, operative and

pathological reports, rehabilitation evaluations, criteria and benefits related to the service request, information on the local delivery system, patient characteristics and

information, information from responsible family members, letters of medical necessity, applicable Health Plan contracts, and applicable federal and state benefit guidelines. See policy titled MPCS 10-Collection and Documentation of Relevant Information for

additional information about the collection and documentation of information used in the utilization review process.

3. Clinical necessity criteria is then applied in a hierarchy fashion that begins with New

York State coverage (NYS) criteria. In instances where NYS coverage criteria is not

available, MPCS follows the least restrictive criteria available. Detailed descriptions on all criteria sets can be found in policy titled MPCS 03- UM Review Criteria and

Criteria Availability.

Please note that medical necessity criteria are intended to be used as guidelines, and are

not intended to replace appropriate clinical judgment. Adaptation of these guidelines may be necessary based on individual needs such as age, comorbidities, psychosocial

factors, home environment, and treatment progress. Characteristics of a patient’s local delivery system are also considered when determining medical necessity. The resultant decision will be based in part on a review of relevant clinical information such as

medical records, objective and evidence based criteria, evaluation of received medical opinions, and any other relevant clinical information. This could also include the



medical opinion of a professional society, peer review committee, or other groups of

physicians. Services are considered medically necessary when they are appropriate and consistent with the diagnosis and treatment of a patient’s medical condition, are

required for the direct care and treatment or management of that condition, the condition would be adversely affected if the requested services are not/were not provided, are provided in accordance with community standards of good medical

practice, are not(primarily)for the convenience of the patient, the patient’s family, the professional practitioner, or another provider, are the most appropriate service for the

condition, are rendered in the most efficient and economical level of care which can safely be provided.

The utilization review in its entirety, as well as any referrals made to other departments for quality of care or case management issues identified during the utilization review

process, is recorded in the designated software systems in accordance to standard UM documentation guidelines.

4. Cases meeting medical necessity criteria are authorized by the utilization reviewer within required time frames, and notifications of the authorization is issued to all

relevant parties in accordance to the requirements outlined in policy titled MPCS 02-

UM Determination & Notification Requirements. All case documentation shall include

the date of the utilization review, the name of the utilization reviewer, a summary of the

clinical information reviewed, a clinical rationale for the decision (or rationale for sending to MD review if applicable), and criteria for which the decision was based

upon. a. Cases not meeting medical necessity criteria or requiring further evaluation are

routed to the Medical Director (MD) for review. Only board-certified physician

reviewers, also known as Medical Directors or Clinical Peer Reviewers, with current, valid, and unrestricted licenses trained in the principles and practices in

utilization review, and with no previous involvement in the member’s health care, may issue adverse determinations.

All requests for services that are experimental/investigational in nature require MD review. An experimental/investigational services is defined as one where

there is insufficient information to determine if the service is of proven benefit for a particular diagnosis or for treatment of a particular condition, one not

generally recognized by the medical community, as reflected in published, peer-reviewed medical literature as effective or appropriate for a particular diagnosis or for treatment of a particular condition, or one not of proven safety for a

person with a particular diagnosis or a particular condition (i.e., which is under evaluation in research studies to ascertain the safety and effectiveness of the

treatment on the well-being of a person with the particular diagnosis or condition). Note that MPCS is responsible for compliance with all applicable requirements of Article 49 of the New York State Public Health Law regarding

requests for experimental or investigations health care services that would otherwise be a covered benefit; except for the determination that the health care

service is experimental or investigational shall be subject to utilization review pursuant to Title 1 of Article 49 of the Public Health Law.



All requests for out-of-network services require MD review. Please see policy

titled MPCS 16- Out of Network Requests for detailed instructions on the process.

b. The physician will document his/her determination in the designated software

system using standard UM documentation guidelines. All cases reviewed by the MD shall include the date of the MD review, name of the MD reviewer, a summary of the clinical information reviewed, a clinical rationale for the decision, and criteria

for which the decision was based upon. The case is then returned to the utilization reviewer for completion. Notifications of the decision are issued to all relevant

parties in accordance to the requirements outlined in policy titled MPCS 02- UM

Determination & Notification Requirements, and all such activity will be captured

by the utilization reviewer in the designated software system.

Frequency of Utilization Review

Utilization review will not be conducted more frequently than is reasonably required to assess whether health care services under review are medically necessary. MPCS will also not modify standards or criteria used to prior approve a service, or reverse a

preauthorization pursuant to NYS Public Health Law §4905(5) unless conditions of 10 NYCRR Part 98-1.13 (n) are met.

Reduction, Suspension, or Termination of Authorized Services

If a health care service has been specifically pre-authorized or approved for an insured by a

utilization review agent, a utilization review agent shall not pursuant to retrospective review revise or modify the specific standards, criteria or procedures used for the utilization review

for procedures, treatment and services delivered to the insured, during the same course of treatment. However, MPCS may reverse approval of a preauthorized treatment or service when the relevant medical information presented upon retrospective review is materially

different from the information that was presented during the preauthorization review, and such medical information existed at the time of the preauthorization, but was withheld from

or not made available to MPCS or the utilization review agent, and MPCS was not aware of the existence of the information at the time of the preauthorization review, and had MPCS been aware of this information, the treatment, service, or procedure being

requested would not have been authorized. The determination is to be made using the same standards, criteria, and/or procedures used during the preauthorization review. MPCS will

also not deny payment for a preauthorized service unless the conditions of Insurance Law §3238 are met.

MPCS may also reverse or revoke preauthorization when it has been determined that there is evidence of fraud, there is a change in the status of the provider from participating to

non-participating (subject to state laws governing continuity of care), there is a change in the member’s benefit plan between the approval data and the date of service, there is evidence that the information submitted was erroneous or incomplete, there is evidence of a

material change in the member’s health condition between the date the approval was provided and the date of treatment that makes the proposed treatment inappropriate for the

member, the member was not covered at the time the health care services were rendered(exception may apply if the member was retroactively disenrolled more than 120 days after the date of service), the member exhausted the benefit after the authorization was



issued and before the service was rendered, the preauthorized service was related to a pre-

existing condition that was excluded from coverage, or the claim was not timely under the terms of the applicable provider or member contract.

If MPCS intends to reduce, suspend, or terminate a previously authorized service within an authorization period, the member must be provided with a written notice at least ten days

prior to the intended action. This notice period is shortened to five days in cases of confirmed fraud. However, notice may be mailed not later than the date of action in

instances where the member dies, signs a written statement requesting termination or giving information requiring termination or reduction of services(where the member understands that this must be the result of supplying information), the member is admitted

to an institution where they are no longer eligible for further services, the member’s address is unknown and there is no forwarding address, the member has been accepted for Medicaid

by another jurisdiction, or the members physician prescribes a change in the level of medical care.

Also note that, when home health services are requested for requested for a hospitalized member prior to discharge, MPCS will not deny, for medical necessity or lack of pre-

authorization, coverage for home care services while the determination is pending. This assumes that all necessary information is submitted to MPCS prior to discharge.

Affirmative Statement Regarding Financial Incentives MPCS makes UM decisions based only on appropriateness of care and coverage

determinations. With respect to utilization review activities, MPCS does not permit or provide compensation or anything of value to its employees, agents, or contractors based on a percentage of the amount by which a claim is reduced for payment or the number of

claims or the cost of services for which the person has denied authorization or payment, or any other method that encourages the rendering of an adverse determination. Any

suspicion of compensation, reward, or financial incentives that would be perceived as affecting utilization decisions would be referred to our compliance department for further investigation. All UM staff are required to sign an affirmation statement on a yearly basis,

which are then stored in their personnel file. Yearly audits are conducted to ensure that affirmation statements have been signed and stored properly. Affirmation statements

regarding incentives are also printed within the client health plan’s member handbooks, provider manuals, and employee newsletters, which are updated at least on a yearly basis and published on their website.

Transfer of Liability

MPCS will not transfer liability for UR activity, actions, or omissions, to any health care provider.

Tracking Mechanism

All utilization review activity in its entirety is tracked and recorded in designated software

systems.

Oversight

MPCS ’ Chief Medical Officer, in collaboration with UM management, has oversight of this policy.



MPCS 05

UM Staff Availability

Policy Statement

The intent of this policy is to demonstrate a process through which members and providers

can communicate with MPCS Utilization Management staff.

Procedure

UM personnel are available during business hours (8:00am-4:30 pm, Monday through Friday, excluding holidays) to answer questions regarding UM decisions, patient care, and

the UM program by calling 1 (800) 683-3781 or by any direct call back numbers given to providers by UM staff. Local and toll free telephone numbers are readily displayed on the member’s ID card, are published on the client helath plan’s website, and are also provided

in written UM determination notices. UM personnel are also available after hours in an on-call capacity at the above listed contact number for issues related to urgent UM requests or

appeals. Toll free fax numbers are published on the health plan’s website and are provided in written UM determination notices. MPCS also offers TDD/TTY services for deaf, hard of hearing, or speech impaired members. These numbers are readily displayed on the health

plan’s website and are also contained in written UM determination notices. Language assistance/interpretation is also available for members. Detailed procedures for using

TDD/TTY and language assistance services are located on the MPCS ’ intranet for UM staff.

MPCS customer service staff follow specific protocols for transferring members, providers, or prospective members who request to speak directly to the UM department. Refer to the PPM titled UM Procedure-Triaging Calls to UM or click on the following link

to access: http://policytech/dotNet/documents/?docid=2625&mode=view

Callers also have the option of leaving a confidential voicemail message with UM

personnel either during or after business hours. These calls are returned promptly the same day or the next business day. UM staff are required to identify themselves by their name,

title, and organization when initiating or returning calls. UM personnel adhere to all applicable minimally necessary disclosure policies and caller authentication requirements

outlined in HIPAA Privacy and Security Regulations during inbound and outbound calls.

Tracking Mechanism

UM staff use designated software systems to track inbound and outbound utilization review communications, which is also utilized for the purpose ensuring adherence, consistency,

and compliance to the above noted processes. Oversight

The Chief Medical Officer, in collaboration with UM management, is responsible for oversight of this policy




MPCS 06 UM Behavioral Health

Policy Statement

The behavioral health utilization review process consists of accepting requests for, and making benefit and clinical necessity determinations on behavioral health care services for

which the health plan determines is subject to the utilization review process. Procedure

MPCS employs appropriately qualified UM personnel with current, valid, and unrestricted licenses to make utilization review determinations on inpatient and outpatient, prospective,

concurrent, retrospective, urgent and non-urgent behavioral health service requests in accordance to the procedures outlined in policy titled MPCS 04- Utilization Review Process. Only appropriately qualified physicians trained in the principles and practices of

utilization review may deny behavioral health requests based on medical necessity. Refer to policy titled MPCS 11-Utilization Management Personnel for full job descriptions and

reviewer accountabilities. Please note that MPCS does not possess a centralized triage function, as behavioral health

assessment occurs directly at the treatment source. Tracking Mechanism


Oversight

MPCS ’ Chief Medical Officer (CMO) and the client health plan’s senior behavioral health

practitioner (physician or PhD level) meet regularly to evaluate policies, procedures, and efficacy of the behavioral health utilization review process. Feedback is then provided to

MPCS UM management for process improvements. New or revised behavioral health utilization review policies and procedures, or any quality improvement initiatives, must be reviewed and approved by MPCS ’ UM Quality Committee.

MPCS ’ CMO, in collaboration with UM management, is responsible for oversight of this

policy.



MPCS 08

Appeals, Grievances, Fair Hearing

Policy Statement

The purpose of this policy is to define appeal and grievance (complaints) processes.

Appeal & grievance processes outlined in this policy vary in accordance to the member’s type of contract. Where processes and time frames differ, this will be specified.

Procedure

Appeals

Appeal procedures apply to adverse medical necessity and experimental or

investigational determinations. Members, their authorized designee, or their health care provider (in connection with retrospective determinations) may file a standard appeal or an expedited appeal A member may also may file an appeal even if they have already

received the service. Appeals can be filed by contacting MPCS at the phone number listed on the adverse determination letter, at the phone number listed on the member’s

ID card or @ 1 (800) 683-3781, or in person/ writing to 1120 Pittsford-Victor Road, Pittsford, NY, 14534. Appeal proceedings can be requested after business hours, on weekends, or on holidays by leaving a message at the telephone numbers listed above.

A representative will respond to the member’s request on the next business day.

Medicaid Managed Care (MMC) and Child Health Plus (CHP) members or their designees have sixty (60) business days [but no more than ninety (90) days] from

receipt of the notice of determination to file an appeal. Members other than MMC and CHP have up to one hundred eighty (180) calendar days. Members filing an appeal

within ten (10) days of the notice of action or by the intended date of an action, whichever is later, that involves the reduction, suspension, or termination of previously approved services may request “Aid Continuing” in accordance with Section 25.4 of the

Medicaid Managed Care Model Contract. Members must be provided with a reasonable opportunity to present evidence regarding the appeal, and allegations of fact or law, in

person as well as in writing. Members must be informed of limited time to present such evidence in the case of an expedited appeal. MPCS must provide members with reasonable assistance with completing forms and other procedural steps for filing an

appeal, including interpretive and/or TTY/TDD services. MPCS must permit the member or a designee, both before and during the appeals process, an opportunity to

examine the member’s case file, including medical records and any other documents and records considered during the appeals process. Members also have the right to designate a representative (including an attorney) to assist him/her in the appeals

process.

MPCS keeps all requests and discussions related to an appeal confidential and will not take any action to penalize or discourage a member or provider from appealing, seeking



dispute resolution, or judicial review of an adverse determination. MPCS fully

investigates the content of the appeal, including all aspects of the clinical care involved (if applicable), and documents its findings in designated software systems. MPCS shall

ensure that decision makers on both standard and expedited appeals were not involved in previous levels of review or decision-making, nor have been involved in the provision of health care to the member in any way. Moreover, MPCS shall ensure that

health care professionals with clinical expertise in treating the member’s condition or

disease are involved.

A file is contained on each appeal, which includes the date the appeal was received at MPCS and a written copy of the appeal. If received orally, a written summary of the

oral action appeal must be sent to the member, and can be included in the acknowledgement letter or separately for the member to review, modify, sign, and

return to MPCS . If the member or provider requests expedited resolution of the appeal, the oral appeal does not need to be confirmed in writing. The date of the oral filing of the appeal will be the date of the appeal for the purposes of the timeframes for

resolution of appeals.

The file also contains a mailed and dated copy of acknowledgement letter, the appeal determination, all clinical and non-clinical information gathered and reviewed during the determination process, the date the determination was made, all oral and written

notice of determinations made, and the titles of the personnel and credentials of clinical personnel who reviewed the appeal.

Member must be allowed the opportunity before and during the appeals process to examine their case file, including medical records and any other documents and records,

and obtain a copy of their appeal case free of charge if requested. Appeal decisions not made within required time frames outlined below will result in a reversal of the initial

adverse determination.

Standard Appeal When a standard appeal request has been received, MPCS will send the member an acknowledgment of his/her appeal in writing within fifteen (15) calendar

days, indicating the address and telephone number of the person or department responsible for rendering a decision. If a determination is reached before the

written acknowledgement is sent, MPCS may include the acknowledgement with the written grievance determination (one notice).

If additional information is required to conduct the appeal, the member (or designee) and the member’s health care provider will be notified in writing within the applicable case time period but no later than fifteen (15) calendar

days of receipt of the appeal to identify and request the necessary information. If, subsequently, the member and/or his/her provider provide only partial

information, the member and his/her provider will be contacted in telephone and in writing requesting and identifying the additional information needed within five (5) business days of receipt of the partial information. The period of time to

make an appeal determination under Section 4904 of the Public Health Law begins upon a health care plan’s receipt of necessary information.



All standard appeals for MMC and CHP members are decided within thirty (30) calendar days from receipt of the appeal. This timeframe of the determination

may be extended for up to fourteen (14) additional days if the member, their designee, or the provider requests an extension orally or in writing, or MPCS demonstrates that the need for additional information is in the member’s best

interest. MPCS must maintain documentation to demonstrate the extension was warranted. Extensions apply to both standard and expedited appeals. The

member (or designee) is notified in writing of this extension. See section of this policy titled Written Notice of Standard & Expedited Appeals for requirements on content of extension notices. Failure by MPCS to make a determination

within the applicable time periods in shall be deemed to be a reversal of the adverse determination.

Written notice of the standard appeal determination will be provided to the member (or designee) and their health care provider (when applicable) within

two (2) business days after the determination is made. See section of this policy titled Written Notice of Standard & Expedited Appeals for requirements on

content of standard appeal notices.

For members other than MMC or CHP, if the appeal relates to a pre-service

matter, a decision is made within thirty (30) calendar day, and written notice of the determination is provided to the member (or designee) and the member’s health care provider (if the provider initiated the appeal) within two (2) business

days after the determination is made, but no later than thirty (30) calendar days after receipt of the appeal request. If the appeal relates to a post-service matter, a

decision is made within sixty (60) calendar days, and written notice of the determination is made to the member (or designee) and the member’s health care provider (if the provider initiated the appeal) within two (2) business days

after the determination is made, but no later than sixty (60) calendar days after receipt of the appeal request.

The notification of appeal determination includes reasons for the determination must be dated and include the date the appeal was filed and a summary of the

appeal, the date the appeal process was completed, and the results and reason for the determination, including the clinical rationale, if any. See section of this

policy titled Written Notice of Standard & Expedited Appeals for additional requirements on content of standard appeal notices.

Expedited Appeal All Plan members and their health care providers have the right to request an

expedited appeal of an adverse medical necessity, experimental, or investigational determination. If the expedited appeal is requested orally, the oral action does not need to be confirmed in writing. If the appeal relates to a

review of continued or extended health care services, additional services rendered in the course of treatment, services in which a provider requests an

immediate review, or a situation in which a delay would seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum



function or any other urgent matter, MPCS handles the appeal on an expedited

basis. The appeal process regarding an adverse determination in which a member’s health care provider believes an immediate appeal is warranted shall

include mechanisms which facilitate resolution of the appeal including, but not limited, to the sharing of information from the member’s health care provider and the Plan by telephone or fax. Reasonable access to MPCS ’s physician

reviewers will be provided within one (1) business day of receiving notice of taking the expedited appeal.

Expedited appeals are not available for retrospective reviews. A request that

does not meet the criteria for an urgent or expedited appeal will automatically default to a standard appeal. The member will be notified in writing within two

(2) business days that the expedited appeal request has been declined, and that the appeal will be reviewed within standard time frames. MPCS will make reasonable effort to provide verbal notice as prompt as possible. The written

notice advising that an expedited review request has been denied must explain that the request will be reviewed under standard timeframes, and include a

description of such time frames, and a statement that oral interpretation and alternate formats of written material for enrollees with special needs are available and how to access the alternate formats. This notice may be combined

with the acknowledgement.

For MMC, CHP, and CHP members, expedited appeal decisions and verbal notifications of such decisions must be made as expeditiously as possible, but no

later than three (3) business days after receipt of the appeal, or two (2) business days after receipt of all necessary information, whichever is less. A written

confirmation of the decision will be provided within 24 hours of the determination. If the final decision is upheld, the written confirmation will be a final adverse determination. A reasonable effort will be made by MPCS to

provide oral notice of the determination to the enrollee and provider at the time the determination is made. See section of this policy titled Written Notice of

Standard & Expedited Appeals for requirements on content of expedited appeal notices.

If a decision is not made within two (2) business days after receipt of all necessary information, the request will be deemed approved. The time frame for

a determination may be extended for up to fourteen (14) days upon member or provider request, or if MPCS demonstrates that additional information is needed, and a delay is in the best interest of the member. If additional

information is required to process the appeal, MPCS will notify the member (or designee) and the member’s health care provider immediately, by telephone of

facsimile, to identify and request the necessary information, followed by written notification. See section of this policy titled Written Notice of Standard & Expedited Appeals for requirements on content of extension notices.

For members with commercial contracts, expedited appeals decisions involving

pre-service events will be made within the lesser of two (2) business days or twenty-four (24) hours of receipt of the appeal request. Written notice will



follow within twenty-four (24) hours of the determination, but not later than

seventy-two (72) hours of receipt of the appeal request. If the final decision is upheld, the written confirmation will be a final adverse determination. See

section of this policy titled Written Notice of Standard & Expedited Appeals for requirements on content of expedited appeal notices. A reasonable effort will be made by the Plan to provide oral notice of the determination to the enrollee and

provider at the time the determination is made. Failure by MPCS to make a determination within the applicable time periods in shall be deemed to be a

reversal of the adverse determination. If there is dissatisfaction with the resolution of the expedited appeal, a standard or external appeal may be filed.

o Written Notice of Standard & Expedited Appeals

All written notices generated during the appeals process, which include

extension and determination notices, must be in an easily understood language, and accessible to non-English speaking and visually impaired members. Notices shall also include that oral interpretation and alternate

formats of written material for members with special needs are available and how to access the alternate formats. Notices are also required to

contain specific language depending on the type of notice generated, which is outlined within the sections below. Notices of final adverse determinations shall comply with all requirements of Article 49 of the

Public Health law and will all applicable federal laws and rules.

If the denial decision is upheld, the standard or expedited written appeal

notice of determination must also include (in addition to the above) the member and the nature of his/her medical condition, the medical service,

treatment or procedure in question, a clear statement describing the basis and clinical rationale for the denial as applicable to the member and clinical information regarding their medical condition, a clear statement

that the notice constitutes a final adverse determination of either a medical necessity or experimental or investigational denial, the date in

which the appeal was filed, a summary of the appeal, date in which the appeal decision was rendered, a description of the health care services that was denied, including as applicable and available, the dates of

services, the name of the facility and/or practitioner proposed to provide the treatment and the developer/manufacturer of the health care service,

the title and credentials of the appeal reviewer, the name, full address, and telephone number of the Plan’s utilization review agent, a contact person from the Plan and his/her telephone number, the member’s

coverage type, a statement that the member may be eligible for an external appeal and the time frames for requesting an appeal ( a copy of

Standard Description and Instructions for Health Care Consumers to Request an External Appeal & external appeal application is sent to the member with the final adverse determination letter), a clear statement

written in bolded text that the forty-five (45) day time frame or four (4) months for member-initiated appeals (effective July 1, 2014, the time

frame for provider-initiated external appeals is sixty ( 60) days] begins upon the receipt of the final adverse determination on the first level



appeal, regardless whether a second level appeal is requested, and that by

choosing to request a second level internal appeal, the time may expire for the enrollee to request an external appeal, the member’s right to

complain to the New York State Department of Health and their toll-free number, a description of member’s fair hearing and aid-to-continue rights for MMC members (see section of this policy titled Fair Hearing

Procedures for detailed information on this process), a statement that the notice is available in other languages and formats for special needs

and how to access these formats.

In addition to the above,

Notice to the member regarding a Plan-initiated extension

includes the reason for the extension, an explanation of how the delay is in the best interest of the member, any additional information required from any source to make its

determination, the member’s right to file a complaint regarding the extension, the process for filing a complaint and

the timeframes within which a complaint determination must be made, the member’s right to designate a representative to file a complaint on their behalf, the member’s right to contact

the New York State Department of Health regarding his or her their complaint , including the NYSDOH’s toll-free number for complaints, and a statement that oral

interpretation and alternate formats of written material for enrollees with special needs are available and how to access

the alternate formats.

Action appeal notices involving upheld restrictions on MMC

members under MPCS ’s restricted recipient program (RRP) must include the effective date of restriction, the scope and

type of restriction, the name, address, and phone number of the RRP provider(s) the enrollee is restricted to, and the right of the enrollee to change an RRP provider.

Action appeal notices involving upheld personal care services

for MMC members must include the number of hours per day, number of hours per week, and the personal care services function (Level I/Level II), that were previously authorized (if

any), that were requested by the Enrollee or their designee (if so specified in the request) , that are authorized for the new

authorization period (if any), and the original authorization period and the new authorization period, as applicable.

Action appeal notices involving upheld prescription medications denials specified in section10.32 (g) of the

Medicaid Managed Care Model Contract must specify that the requested medication is provided when the prescriber



demonstrates that, in their reasonable professional judgment

[either by consistency with U.S. Food and Drug Administration approved labeling or use supported in at least

one of the Official Compendia as defined in federal law under the Social Security Act §1927 (g)(1)(B)(i)], that the medication is medically necessary and warranted to treat the

member, and whether the appeal is upheld because the necessary information to complete the request was not

provided (including a description of the information needed) prior to the review time frame expiring, or the prescriber’s reasonable professional judgment was not demonstrated prior

to the review time frame expiring.

External appeal

New York State's External Appeal Law provides the opportunity for the external

review of final adverse determinations based on lack of medical necessity, experimental or investigational treatment, a clinical trial, or out-of-network

services that are not materially different from an alternate service available within the health Plan’s network. Further, a member, the member's designee and, in conjunction with concurrent and retrospective adverse determinations, a

member's health care provider has the right to request an external appeal. The provider may only file an external review on their own behalf for concurrent and

retrospective adverse determinations. As of January 1, 2010, this law also applies to rare diseases, which are defined as any life threatening or disabling condition that is or was subject to review by the National Institutes of Health's

Rare Disease Council or affects less than 200,000 US residents per year and there is no standard health service or treatment more beneficial than the

requested health service or treatment. To qualify as a rare disease, the condition must be certified by an outside physician specialized in an area appropriate to treat the disease in question, the patient should be likely to benefit from the

proposed treatment and the benefits must outweigh the risks.

An external appeal must be submitted within the applicable time frame upon receipt of the final adverse determination of the first level appeal, regardless of whether or not a second level appeal is requested. If a member chooses to

request a second level internal appeal, the time may expire for the member to request an external appeal. MPCS may not require Medicaid Managed Care

members to exhaust a second level of internal appeal to be eligible for external appeal.

Circumstances for which an external appeal may be filed include when the member has had coverage of a health care service, which would otherwise be a

covered benefit under a subscriber contract or governmental health benefit program, denied on appeal, in whole or in part, on the grounds that such health care service is not medically necessary and has rendered a final adverse

determination with respect to such health care service or both MPCS and the member have jointly agreed to waive any internal appeal. If the member and



Plan jointly agreed to waive the internal appeal process, the letter agreeing to

such waiver and the Final Adverse Determination with all required language must be provided within twenty-four (24) hours of the agreement.

An external appeal may also be filed when the member has had coverage of a health care service denied on the basis that such service is experimental or

investigational and the denial has been upheld on appeal or both MPCS and the member have jointly agreed to waive any internal appeal and the member's

attending physician has certified that the member has a life-threatening or disabling condition or disease for which standard health services or procedures have been ineffective or would be medically inappropriate, or for which there

does not exist a more beneficial standard health service or procedure covered by MPCS , or for which there exists a clinical trial or rare disease treatment and

the member's attending physician (who must be a licensed, board-certified or board-eligible physician qualified to practice in the area of practice appropriate to treat the member's life-threatening or disabling condition or disease) must

have recommended either a health service or procedure [including a pharmaceutical product within the meaning of PHL 4900(5)(b)(B)] that, based

on two documents from the available medical and scientific evidence, is likely to be more beneficial to the member than any covered standard health service or procedure, or in the case of a rare disease, based on the physician's certification

required by Section 4900 (7)(g) of the PHL and such other evidence as the member, the designee or the attending doctor may present, that the requested

health service or procedure is likely to benefit the member in the treatment of the enrollee's rare disease and that the benefit outweighs the risks of such health service or procedure or a clinical trial for which the member is eligible. Any

physician certification provided under this section shall include a statement of the evidence relied upon by the physician in certifying his or her

recommendation and the specific health service or procedure recommended by the attending physician would otherwise be covered under the policy except for MPCS 's determination that the health service or procedure is experimental or

investigational.

For external appeals of out-of-network denials, the member must have had coverage of the health care services, which would otherwise be a covered benefit under the member's benefit plan which is denied on appeal, in whole or in part,

on the grounds that such health service is out-of-network and an alternate recommended health service is available in-network, and MPCS has rendered a

final adverse determination with respect to an out-of-network denial or both MPCS and the member have jointly agreed to waive any internal appeal; and the member's attending doctor, who shall be a licensed, board-certified or

eligible physician qualified to practice in the specialty area of practice appropriate to treat the member for the health service sought, certifies that the

out-of-network health service is materially different from the alternate recommended in-network service, and recommends a health care service that, based on two documents from the available medical and scientific evidence, is

likely to be more clinically beneficial than the alternate recommended in-network treatment and the adverse risk of the requested health service would



likely not be substantially increased over the alternate recommended in-network

health service.

Members or providers may obtain an external appeal application by contacting the New York State Department of Financial Services (NYSDFS) at 1 (800) 400-8882 or via its website at www.dfs.ny.gov. An application can also be

obtained by contacting the Plan at the telephone number listed on member’s identification card @ 1 (800) 683-3781. MPCS provides members with a copy

of the standard description of the external appeal process as developed jointly by the Commissioner and Superintendent, including a form and instructions for requesting an external appeal along with a description of the fee, if any, charged

to members for an external appeal, criteria for determining eligibility for a waiver of such fees based on financial hardship, and the process for requesting a

waiver of such fees based on financial hardship with a notice of a final adverse determination for medical necessity and experimental or investigational denials, with the written confirmation to waive MPCS ’s internal appeal process, and

within three (3) business days of a request by a member or designee. MPCS also provides a form and instructions, developed jointly by the Commissioner and

Superintendent, for a member’s health care provider to request an external appeal in connection with a retrospective adverse utilization review determination under Section 4904 of the Public Health law, within three (3)

business days of a health care provider’s request for a copy of the form. MPCS may charge the provider up to $50 for the appeal. The charge is refunded if the

decision is overturned.

The application will provide clear instructions for completion and filing an

external appeal. The member must release all pertinent medical information concerning their medical condition and request for services.

A practitioner appealing on his/her own behalf must submit the application within sixty (60) days [ forty-five (45) days before July 1, 2014) from the date of

the final adverse determination of the first level appeal. The member and member's designee (including the provider in the capacity of the member's designee) may submit the same form within four (4) months of the final adverse

determination. If the member files on their own behalf, signed applications authorizing the release of medical records must also be sent to the NYSDFS

along with the application.

The NYSDFS then screens applications and assigns eligible appeals to state-

certified external appeals agents, and then notifies both the filer and MPCS whether the request is eligible for appeal, provides explanation thereof and sends

a copy of the signed release form. MPCS will provide medical and treatment records and clinical standards used to make the utilization review determination within three (3) business days of receiving the agent's information and

completed release forms. For an expedited appeal, this information will be provided within twenty-four hours of receipt.

http://www.dfs.ny.gov/



For standard cases, an expedited appeal determination will be made within thirty

(30) days from receipt of the member's request, in accordance with the commissioner's instructions. However, the external appeal agent shall have the

opportunity to request additional information from the member, practitioner, and Plan within the thirty (30) day period, in which case the agent shall have up to five (5) additional business days to make a determination. For urgent

circumstances, an expedited review may be requested, for which a decision will be rendered in seventy-two (72) hours.

Once a decision is made, the agent will make every reasonable effort to notify the member and MPCS of the decision immediately by phone or fax. This will

be followed immediately by a written notice. The agent’s decision is final and binding on both the member and MPCS ; however, a Fair Hearing determination

supersedes an external appeal determination for MMC enrollees. See the section of this policy titled Fair Hearing Procedures for additional information on this process.

MPCS may charge the member fee of up to $50 per external appeal; provided

that, in the event the external appeal agent overturns the final adverse determination of MPCS , such fee shall be refunded to the member. Notwithstanding the forgoing, MPCS shall not require the member to pay any

such fee if the member is a recipient of medical assistance or is covered by a policy pursuant to New York State Public Health Law. MPCS shall not require

the member to pay any such fee shall pose a hardship to the member as determined by MPCS pursuant to Section 4910.3 of the NYS Public Health Law and Section 4910 (c) of the Insurance Law. For retrospective adverse

determinations, MPCS may charge the appealing health care provider up to $50 for each appeal, provided, however, that no fee may be charged to a member

for a health care provider’s external appeal of a retrospective adverse determination is overturned on external appeal, the full amount of the fee shall be refunded to the appealing health care provider.

Grievance

A member (or designee) has the right to file a grievance (or complaint) when concerned with any aspect of services rendered by MPCS that does not pertain to an adverse

medical necessity determination, or an experimental or investigational determination. Examples of intangible complaints include (but are not limited to) dissatisfaction with

treatment received from MPCS , its practitioners, or benefit administrators, quality of care issues, access to care issues, alleged violation of privacy practices and policies, and fraud and abuse. Additionally, if a member calls the Plan with a concern that

cannot be resolved immediately on the telephone, the member is advised of the right to file a level one (1) grievance. Grievance procedures may also be used to resolve a

dispute in which MPCS decided that the member did not meet requirements for coverage of a particular service, or that an out-of-network authorization was unnecessary. All member concerns and grievance requests are documented and kept

confidential. MPCS will not take any action to penalize or discourage a member or provider from grieving or seeking dispute resolution. Grievance decisions on UR



matters not made within required time frames will result in a reversal of the initial

adverse determination.

A grievance may be filed by contacting MPCS via the phone number listed on the member’s ID card or @ 1 (800) 683-3781. An advocacy associate will document a summary of the grievance on a compliant form and submit the form to the member for

signature. Grievances can be submitted in person or in writing to 1120 Pittsford-Victor Road, Pittsford, NY 14534. Grievance proceedings can be requested after business

hours, on weekends, or on holidays by leaving a message at the telephone numbers listed above. A representative will respond to the member’s request on the next business day. MMC and CHP members have sixty (60) business days to file a level

one (1) grievance from receipt of a decision, and sixty (60) business days to file a second level grievance upon receipt of a first level grievance decision for which they

were dissatisfied with. Members other than MMC and CHP have up to one hundred eighty (180) calendar days to file a level one grievance from receipt of a decision, and one hundred eighty (180 )calendar days to file a second level grievance upon receipt of

a first level grievance decision for which they were dissatisfied with.

Upon request, MPCS will provide a written copy of the grievance procedure, readable at a fourth grade level. MPCS also provides members with reasonable assistance with completing forms and other procedural steps for filing a grievance, including

interpretive and/or TTY/TDD services.

The member is issued a written acknowledgement within fifteen (15) calendars days upon MPCS ’s receipt of a level one (1) or level two (2) grievance request [please note

that level two(2) grievances are considered “complaint appeals” by MPCS ]. The acknowledgement letter will include the name, address, and telephone number of the

individual or department handling the grievance. The acknowledgement will also inform the member of the status of the grievance, and advise whether additional information is required to process the grievance. If a determination is reached before

the written acknowledgement is sent, MPCS may include the acknowledgement with the written grievance determination (one notice).

If additional information is required on a level one (1) or level two (2) grievance that is

being processed within standard time frames, MPCS will identify and request information in writing from the member and provider within the applicable case time

period, but no later than fifteen (15) calendar days upon receipt of the request. If additional information is required on a grievance that is being processed in expedited time frames, MPCS will expeditiously identify and request the information via phone

or fax to the member and provider followed by written notification to the member and provider. If additional information is not received on intangible complaints, MPCS

will issue a written statement that a determination could not be made, and also note that the time frame to provide such information has expired.

An individual who is not subordinate to the individual that rendered the initial determination will review non-clinical level one grievances. Non-clinical level two (2)

grievance determinations are made by (or in conjunction with) qualified personnel at a



higher level than the personnel who made the original level one grievance

determination. If either a level one (1) or level two (2) grievance involves a clinical

matter, decision makers who were involved in previous levels of review or decision-

making cannot be involved in subsequent grievance determinations. Moreover, MPCS shall ensure that health care professionals with clinical expertise in treating the

member’s condition or disease are involved. MPCS fully investigates the content of the

grievance, including all aspects of the clinical care involved (if applicable), and documents its findings in designated software systems.

In instances where a delay would significantly increase the risk to a member’s health, both initial and second level grievance decision and verbal notice will be issued within forty-eight (48) hours after receipt of all necessary information (or in some other form

of communication if verbal notice is not possible) and no more than seven (7) days from the receipt of the compliant for MMC and CHP members. All other complaints

(including intangible complaints) shall be resolved within forty-five (45) days after the receipt of all necessary information, and no more than sixty(60) days from receipt of the complaint. Written notice to follow within three (3) business days.

For members other than MMC and CHP, if the initial or second level grievance relates to a pre-service matter, a decision and written notice of the decision will be issued

within fifteen calendar (15) days of receipt of the grievance and all necessary information. If the initial level grievance relates to an urgent matter, a decision and verbal notice of the decision will be issued within forty-eight (48) hours of receipt of

the grievance and all necessary information. Written notice will then follow within twenty-four (24) hours of the determination. For urgent second level grievances, a

decision and verbal notice of the decision will be issued within twenty-four (24) hours of the grievance and all necessary information, and written notice will follow within twenty-four (24) hours of the decision. If the initial or second level grievance relates to

a post-service matter, a decision and written notice of the decision will be issued within thirty (30) calendar days of receipt of the grievance and all necessary information.

Intangible grievances must be resolved and the member notified within forty-five (45) calendar days after receipt of information.

All written notices generated during the grievance process, which include extension and

determination notices, must be in an easily understood language, and accessible to non-English speaking and visually impaired members. Notices shall also include that oral interpretation and alternate formats of written material for members with special needs

are available and how to access the alternate formats. Level one (1) and level two (2) grievance notice of determinations shall include the name, title, and credentials of the

reviewer, a detailed reason for the determination, the clinical rationale for the determination in cases where the determination has a clinical basis, information regarding the member’s option to contact the NYSDOH with his/her complain,

NYSDOH’s contact information which includes their toll-free number, and instructions for any further appeal, if applicable.

MPCS maintains a file on all grievances. Members must be allowed access to their file

free of charge. Each file includes (but is not limited to) the date in which the grievance was received, a copy of the compliant (if written), the date of (and copy of) the written



acknowledgement of the grievance that sent to the filer, chronology of events related to

the grievance, all documents and records considered in the grievance decision, the date and outcome of the grievance decision, titles and/or credentials of personnel who

reviewed the grievance, necessary documentation to support any extensions, the member or provider’s requests for an expedited compliant appeal and Plan’s determination to accept an expedited compliant appeal(if applicable), compliant appeal

determination and determination date (if applicable), titles and/or credentials of personnel who reviewed the complaint appeal (if applicable), and complaints

unresolved for greater than forty-five (45) days (if applicable). All complaints are logged and will be included in the quarterly HPN Complaint report submitted to New York State Department of Health.

Fair Hearing Procedures

In addition to the grievance and appeal procedures outlined above, MMC members

may request a Fair Hearing regarding an adverse determinations on enrollment, disenrollment and eligibility, and regarding the denial, termination, suspension or reduction of a clinical treatment or other benefit package service. A member may also

seek a Fair Hearing for a failure by MPCS to act with reasonable promptness with respect to such services. A member may also file an Fair Hearing even if they have

already received the service. The member must ask for a fair hearing within sixty (60) days from the date noted on the Denial of Benefits under Managed Care Notice form, which is included with adverse determination notices issued by MPCS (see policy titled

UM 02- UM Determination & Notification Requirements for a copy of this form). This form outlines a member’s Fair Hearing rights, as well as instructions on how to file a Fair

Hearing.

Members may request a Fair Hearing via telephone at (800) 342-3334, via fax at (518)

473-6735, via internet at www.otda.ny.gov, or via mail at New York State Office of Temporary and Disability Assistance, Office of Administrative Hearings, Managed

Care Hearing Unit, P.O. Box 22023, Albany, NY 12201. Once the fair hearing is requested, the member will receive notice from the fair hearing office with the time and place of the hearing. Members have the right to obtain copies of their case file in

preparation of the hearing by contacting the New York State Office of Temporary and Disability Assistance using the contact information noted above. This information is

provided within a reasonable time before the hearing. Documents will be mailed only if the member requests they be mailed. Members also have the right to designate an individual to represent them during Fair Hearing proceedings.

A member requesting Fair Hearing within ten (10) days of the notice of action or by the

intended date of action (whichever is later) that involves the reduction, suspension, or termination of previously approved services, or the intent of MPCS to restrict the member under the restricted recipient program, may request to continue the services

pending the Fair Hearing decision. If the Fair Hearing officer grants a continuation of services, the member will continue to receive services until the Fair Hearing

determination is made. If the Fair Hearing is decided against the member, the member may be liable for the cost of any continued benefits.

http://www.otda.ny.gov/



Members may request a Fair Hearing from the state and still file an external appeal, or

vice versa. In some cases, the member may be able to continue to receive the terminated, suspended, or reduced services until the fair hearing is decided. If members

asks for both a Fair Hearing and an external appeal, this decision will be made by the Fair Hearing office.



MPCS 09

UM Inter-Rater Reliability

Policy Statement

The overall effectiveness of the UM Program is evaluated on an annual basis using

multiple measures. One such measure includes inter-rater reliability audits Under the direction of the CMO, findings of these measures are provided to MPCS ’ Quality

Committee for review and recommendations. Monthly audits of individual UR charts and staff performance appraisals are also in place to help assess for strengths and improvement opportunities.

Procedure

Inter-rater reliability audits are conducted on a quarterly basis to ensure that UM staff and Medical Directors are consistently applying criteria used to make pre-service, concurrent, and post-service utilization review determinations for both inpatient and outpatient

services.

This methodology ensures consistency measures required of the UM decision making process are monitored throughout the year, and opportunities for individual and/or team development opportunities are implemented as needed.

For each inter rater audit, UM Quality staff applies the procedure commonly referred to

as the NCQA “8/30 methodology” file sampling procedure. The procedure involves randomly selecting a sample of 8 completed UR cases. The principles apply to the universe of health care organizations that the NCQA accredits. If any of the 8 cases fall

outside the standards that NCQA requires for file review, than an additional random sample of 22 UR cases are reviewed, totaling 30 cases.

Detailed results are then shared with the department. Remediation is conducted on all cases where 100% inter- rater reliability is not achieved. Findings and interventions of

inter-rater reliability audits are reported to the MPCS QM Committee at least annually.

The CMO oversees the administration of inter-rater audits to the physician review staff. Physician review staff complete no less than inter-rater audits on a yearly basis, and the same process noted above is followed for facilitation of the inter-rater audits, scoring, and

remediation.

Tracking Mechanism UM Management will maintain a file of these audits for review for trending and

corrective action activities. Findings and interventions of this process are reported to the Quality Committee as well.



Oversight





MPCS 10 Collection and Documentation of Relevant Information for UR

Determinations

Policy Statement

MPCS has a systematic and consistent process for collecting and documenting

information utilized to make UM decisions. Such guidelines are designed to assure that all required and relevant information has been collected in a manner that is not overly burdensome to the member, provider, or facility. All information is solely for the purpose

of utilization, quality, and care management usage.

Procedure

Information obtained for utilization review decisions come from many sources. The amount and/or type of data required to make a utilization review determination depends

on the circumstances of the case. Only appropriately trained personnel (health care professionals, medical record technologists, or administrative personnel) who have

received appropriate training may obtain information from health care providers for use during the utilization review process.

Information may be collected via telephone, fax, mail, or on-site from a member’s primary care physician, specialist, ancillary, or institutional provider involved in the

member’s care. Collected information is then reviewed against established criteria and guidelines to make utilization review determinations.

MPCS maintains procedures on data sources gathered for UM decision making, and standards for documenting the request, receipt, processing, and storing of such data.

Data sources that may be gathered for UM decision making may include, but are not limited to:

office and/or hospital records that may include a history of illness, psychosocial issues, diagnostic testing results, clinical exams, treatment plans, and progress

notes,

evaluations from and conversations with applicable health care providers,

photographs,

operative and pathological reports,

rehabilitation evaluations,

criteria and benefits related to the service request,

information on the local delivery system,

patient characteristics and information,

information from responsible family members,

letters of medical necessity,

applicable health plan contracts, and

applicable federal and state benefit guidelines



UR personnel will adhere to the following guidelines collecting information and data for review determinations:

Efforts will be made to gather information for UM determinations during the

initial contact with the health care provider. Additional contacts for further information will be performed as necessary. Adverse determinations will not be

issued due to a lack of information unless reasonable attempts were made to obtain the information from the member, their designee, or their provider.

Sources of information will be confirmed, and verification of information will be performed where applicable.

Requests for medical record documentation will only be required in extenuating

situations, or when needed to confirm medical necessity, and/or appropriateness of health care services. Staff will not routinely request copies of medical records of all patients reviewed, and UR staff may request copies of partial or completed

medical records retrospectively.

Staff will collect only such information as is necessary to make an appropriate determination and will not routinely require health care providers to code

requests or submit medical records for all patients.

During pre-service or concurrent review, copies of medical records will only be

required when necessary to verify that the health care services subject to review are medically necessary. Only necessary or relevant sections of the medical

record will be required.

Clinical data considered to be patient specific will be kept confidential and shared with only those individuals who are authorized to receive such information. Confidentiality of medical records is maintained in accordance with

applicable laws and regulations.

Documentation of review activities will be clear and concise to facilitate review by another staff member.

Clinical information will be documented electronically or maintained in hard

copy. Computer-based information is protected, and those who have appropriate security clearance can only access screens. Supplemental medical information provided during the review process or the administrative appeals process will be

filed and maintained in a secure location. Access to this file will be available only to authorized personnel.

MPCS will not conduct utilization review at the site of the health care unless conditions of NYS PHL 4905 (9) are met. MPCS will not base an adverse

determination on a refusal to consent to observe the provision of any health care service.



When on-site record reviews are required to make a utilization review

determination, MPCS UM staff will schedule all facility visits in advance with appropriate facility staff. If requested by a health care provider, UM staff will

register with the appropriate contact person, if available, prior to requesting any clinical information or assistance from the health care provider.

Whenever possible, reviews are to be scheduled at least one business day in advance. In doing so, MPCS will consult with the facility to outline the purpose and scope of the visit, identify with the facility any reasonable documentation

MPCS is required to produce before the visit (such as nursing licenses or immunization records), and to identify all facility rules and regulations that UM

staff are expected to follow during their visit. Prior to the site visit, UM staff will request that charts requiring review are made available at the time of the established site visit. If this option is unavailable, the chart requests will be

requested at the time of the site visit. Upon arrival, MPCS staff will identify himself or herself by name, and the name of his or her organization, including

displaying photographic identification which includes the name of the utilization review agent and clearly identifies the individual as representative of the utilization review agent. An identification badge will be worn in accordance with

facility policies and procedures, and MPCS staff will adhere to all facility rules at all times during their on-site visit (a waiver to do so will be signed if

required). Depending on facility rules, UM staff will be directed/escorted to the designated area where the chart reviews will be conducted. The UR will assess the identified charts for the necessary information required for the utilization

review determination. In rare situations where interviewing a member or observing the provision of any health care to a member is necessary for a

utilization review determination (particularly in instances of concurrent review), consent must be obtained from the member (or member’s designee) in accordance to NYSDOH regulations. UM personnel are required to follow all

Plan policies (as well as facility policies) when accessing confidential information during the on-site review process. Additional information on MPCS

’s confidentiality requirements are referenced in policy titled UM 12- Confidentiality. The on-site review process in this subsection does not apply to MPCS ’s health care professions who provide direct care, case management

services, or make onsite discharge decisions.

At a minimum, chart documentation included as part of the decision making

process should include thee type of service request, date of the initial request, date of the review, names of all UM personnel involved in reviewing the case,

name of clinician(s) that provide clinical information, date(s) and time(s) of all attempts to contact providers, date(s) that all of the necessary information was

requested and received, a summary of all clinical information collected, criteria used to make the determination, rationale to how clinical information met or did not meet criteria for the service requested, number of days and dates approved or

not approved. Staff are informed of documentation guidelines during their initial



training, and compliance will be monitored through the department’s routine performance monitoring and evaluation process.

Tracking Mechanism


Oversight




MPCS 11 Utilization Management Personnel

Policy Statement

MPCS employees appropriately licensed and qualified utilization review professionals that require licensure and/or certifications to perform the functions of their position, and

therefore must meet licensure and scope of practice requirement outlined in Section 8 of the New York State Education Law, and are also expected to maintain current, valid, and unrestricted licenses and/or certifications during their employment.

Procedure

Job descriptions for each category of personnel involved in the UM process are listed below in this section, and are also on file and available within the UM department.

Verification of employee licensure and/or certification from the issuing agency is performed by Human Resources and/or UM management upon hire, and at least once per

year (preferably during annual review) by UM management during the course of employment. Verification is conducted by using the New York State Education Department’s on-line verification tool at http://www.op.nysed.gov/opsearches.htm. A

printed copy of the verification is then placed in the employee’s personnel file. Management is to notify HR immediately with any change of licensure and/or certification

status. MPCS maintains records of all applicable licenses and/or certifications required to perform utilization review activities (delegated or otherwise) for the duration of any delegation agreement, and for six (6) years after its termination

Practicing without a current, valid, and unrestricted license and/or certification may negatively impact employment. As such, license and/or certification renewal is the

responsibility of the employee and must be completed prior to the expiration date of the license/certification. Copies of renewed licenses and/or certifications must be given to UM

Management and Human Resources upon receipt. Employees must also to notify UM management and Human Resources of any changes to license and/or certification status (i.e. non-renewal, revoked, suspended, etc.).

MPCS also provides comprehensive training and support for staff involved in utilization

management activities in efforts to ensure consistent service and quality interactions for the members and providers we serve. Training and orientation plans are structured to provide education on quality management, operating system, updates, revisions, and

application of utilization management criteria, case documentation, case management, members’ rights and responsibilities, product benefit plans, preventive care services

guidelines, customer service skills, utilization review appeal and grievance processes, principles and procedures of intake-screening and data collection, supplemented by day-to-day supervision by licensed health care professionals, confidentiality, regulatory

compliance, and HIPAA compliance.

http://www.op.nysed.gov/opsearches.htm



Chief Medical Officer

A board-certified senior physician with a current,

valid, and unrestricted license, trained in the

principles and practices of utilization review, is

accountable for the direct oversight of UM

program and its components. The CMO oversees

activities that include utilization review, quality

assurance, and regulatory compliance. The CMO

provides guidance and leadership to UM

management and has direct responsibility for all

corporate internal and external reporting,

utilization monitoring, quality improvement,

financial performance, and implementing

methods of reducing inappropriate utilization.

Physician Reviewers

MPCS utilizes board-certified physicians

reviewers, also known as Medical Directors, with

current, valid, and unrestricted licenses who are

trained in the principles and practices of

utilization review to conduct utilization review

on cases not meeting criteria for approval. Only

physicians, under the supervision of the CMO,

may issue adverse determinations.

Clinical Peer Reviewers

Board-certified physicians with current, valid,

and unrestricted licenses who are trained in the

principles and practices of utilization review

serve as clinical peer reviewers. MPCS

maintains and adheres to written procedures for

accessing clinical peer reviewers from

appropriate areas to assist with utilization review

determinations. See Appendix A of this policy

for a list vendors and practitioners who offer

clinical peer reviewer services.

Manager, Utilization Management

This position possesses a current, valid, and

unrestricted license in their scope of practice,

and is trained in the principles and practices of

utilization review. The Manager of Utilization

Management reports directly to the Chief

Operations Officer, and has an indirect reporting

relationship with the CMO. This individual’s

primary responsibility is for Medical and

Behavioral Health Utilization Review

operations. This includes staff training, staff

oversight, developing key operational metrics

for UM, creating monitoring tools, analyzing

results, identifying barriers, and preparing

reports to senior leadership regarding

operational performance. Responsibilities also

include managing the process for measuring,

reporting, and communicating about UM

initiatives across the organization. This position

cannot independently make adverse medical

necessity (including

experimental/investigational) determinations.

Supervisor, Utilization Management

Under the direction of the UM Manager, this

position possesses a current, valid, and





utilization review. Primary responsibilities

include oversight of daily operations, quality

improvement, and clinical compliance.

Responsibilities also include direct utilization

review as needed by the department. This

position cannot independently make adverse

medical necessity (including


Team Leader, Utilization Management


position possesses a current, valid, and



utilization review. Primary responsibilities

include providing daily oversight to the UM

staff, serving as the first level of contact for staff

questions and complaints, monitoring staff

absences, arranging for coverage, assessing staff

workload, monitoring for regulatory compliance,

and assisting in the development of policies and

procedures as needed. Responsibilities also

include direct utilization review as needed by the

department. This position cannot independently

make adverse medical necessity (including


Utilization Reviewer,

Registered Nurse or Licensed Social

Worker


position is a registered nurse or licensed social

worker who possesses a current, valid, and

unrestricted licenses within their scope of

practice, and is trained in the principles and

practices of utilization review to make

utilization review determinations on prospective,

concurrent, and retrospective service requests

using established guidelines. This includes

obtaining and processing clinical information

from members and providers as needed,

documenting all utilization review activity

within required standards, providing care

coordination for members with immediate

and/or long term medical and/or behavioral

health care needs, and making referrals to

prevention programs and case management

services. This position cannot independently

make adverse medical necessity (including


Other responsibilities include, but are not limited

to, acting as a resource to the provider

community and claim reviews as needed.

Utilization Reviewer,

Licensed Practical Nurse


position is a licensed nurse who possesses a

current, valid, and unrestricted licenses within

their scope of practice, and is trained in the



principles and practices of utilization review to

make utilization review determinations on

prospective, concurrent, and retrospective

service requests using established guidelines.

This involves reviewing and approving services

under specific protocols, preparing cases that

may not meet approval for physician review, and

documentation of all utilization review activity

within required standards. This position cannot

independently make adverse medical necessity

(including experimental/investigational)

determinations. Other responsibilities include

making referrals to prevention programs and

case management as appropriate, acting as a

resource to the provider community and claim

reviews as needed, researching and responding

to both internal and external member and

provider complaints and appeals and Fair

Hearings, logging and reporting outcome

resolution following regulatory guidelines, and

disseminating outcomes to appropriate parties at

the Plan for internal follow up as needed.

UM Long Term Support Services (LTSS)

Coordinator



worker who possess current, valid, and






using established guidelines . The LTSS

Coordinator oversees the daily operations

associated with managing LTSS benefit,

including assisting in the development of

policies and procedures, serving as the first level

contact for provider, member, and staff inquiries

on the LTSS benefits, assessing staff workload,

and monitoring for regulatory compliance. This

position will also include utilization review as

business needs dictate, which includes obtaining

and processing clinical information from

members and providers as needed, documenting

all utilization review activity within required

standards, providing care coordination for

members with immediate and/or long term

medical and/or behavioral health care needs, and

making referrals to prevention programs and

case management services. This position cannot



determinations.

UM Triage & Training Coordinator Under the direction of the UM Manager, this


worker who possess current, valid, and








using established guidelines . The UM Triage &

Training Coordinator is primarily responsible for

the equitable distribution of utilization reviews

among the UM staff in accordance to review

priority and complexity to ensure that individual

productivity requirements and departmental time

frame metrics are tracked, met, and maintained

on a daily basis. This position is also

responsible for training both new and current

UM staff on material associated with the

utilization review process, which may include

(but is not limited to), use of UM business

systems, policies and procedures, and benefit

guidelines. Responsibilities may also include

utilization review as business needs dictate,

which consists of obtaining and processing

clinical information from members and

providers as needed, documenting all utilization

review activity within required standards,

providing care coordination for members with

immediate and/or long term medical and/or

behavioral health care needs, and making

referrals to prevention programs and case

management services. This position cannot



determinations.

Clinical Operations Specialist Under the direction of the UM Manager, the

Clinical Operations Assistant provides

administrative support to the UM Manager and

department. The position also provides project

support to other clinical managers, the Chief

Medical Officer, and the Chief Operating

Officer as required. This position cannot



determinations.



Customer Service Representatives Non-licensed personnel responsible for initial

screening and data collection of eligible member

requests for proposed health care. This process

may also involve approving service requests

under specific protocols for eligible members.

Customer Service Representatives are not

employees of the UM department, however,

their responsibilities include intake activity and

triage of UM service requests, which is

ultimately overseen by the CMO. This position

cannot independently make adverse medical

necessity (including



The Chief Medical Officer, in collaboration with UM Management and the Human Resource Department, is responsible for the tracking and oversight of this policy.

Appendix A –Clinical Peer Reviewers

Vendor- MRIoA

Medical Review Institute of America

2875 South Decker Lake Drive

Suite #300 Salt Lake City, UT 84119 1-800-654-2422

[email protected]

MRIoA maintains a clinical review panel of actively practicing board-certified physicians and specialists. Reviewers are sub-specialty matched and have procedural experience with the topic(s) in question. Criteria and/or published references are included with every

review. MRIoA is licensed for IRO/UR review in all states where required. Their on-site medical directors/clinical nurse auditors do post-review quality checks on every case. MRIoA also holds dual URAC accreditations and certifications by NCQA and SSAE 16.

mailto:[email protected]



MPCS 12

Confidentiality

Policy Statement

The workforce of MPCS , which includes employees, physicians, committee members,

vendors, and consultants, requires access to confidential information. All confidential information shall be protected from unauthorized or inappropriate access, use or disclosure and, further, that all workforce members have a duty to safeguard confidential

information in accordance with state and federal law, rules, and regulations, which includes, but is not limited to, the Health Information Privacy and Accountability Act

(HIPAA). As such, MPCS has adopted and maintains organizational confidentiality policies. UM

staff abide by organizational policies and procedures to ensure adherence to managing confidential information within the UM department. Organizational policies are

available electronically on the MPCS ’ intranet and a hard copy is filed within the UM department which is available for staff reference at all times. In essence, MPCS ’ confidentiality policies dictate that all confidential information must be afforded

protection from any unnecessary access, use, or improper disclosure. Please note that minimum necessary guidelines will be followed when releasing PHI from the UM

Department.

Procedure

The guiding principles of MPCS ’ confidentiality polices include (but are not limited to) the following. Please refer to MPCS ’ organizational policies and procedures for full details.

Only appropriately trained members of MPCS ’ workforce will access, utilize,

and disclose confidential information, and only as necessary to perform their assigned functions. Not complying with MPCS ’ confidentiality policies is

grounds for excluding, not hiring, or terminating an individual or entity. All workforce members are given MPCS ’ confidentiality policies to review at

the time their employment or relationship with MPCS begins. Current and prospective workforce members will be required to acknowledge their

understanding of MPCS ’ confidentiality policies and procedures, and their willingness to abide by them as a condition of employment or as a condition of doing business with MPCS . Workforce members will be required to

update their acknowledgment of an agreement with the confidentiality policy on an annual basis or as needed basis.

MPCS provides delegated UM functions for health plans that require their contracted providers to maintain policies and procedures for ensuring confidentiality of member records and information. Said health plans also



have in place a process for assessing the adequacy of their contracted providers’ policies and procedures on maintaining the confidentiality of the patients served.

Confidential information will be kept protected and secure at all times as per

policy. All confidential information will be handled in a manner that assures the confidentiality of involved members, patients, including all verbal and written

communication, reports, minutes and committee actions and/or decisions.

Confidential information will be disclosed in as limited a manner as possible while still allowing the task necessary for the business purposes of MPCS to be accomplished.

All PHI is kept strictly confidential. It is generally used only for internal

administrative purposes and for coordinating benefits with other health insurance plans. Confidential information is shared only with the insured, the insured’s

designee, the insured’s health care provider and those who are authorized by law to receive such information. PHI may be requested by numerous individuals and agencies, however, with some exceptions, it should not be released without

member authorization except with approval from our Privacy and/or Legal Department. Whenever possible, information shared for the purpose of treatment,

payment or health care operations will be provided in a de-identified, blinded, encrypted, aggregated, or summarized format. Summary data shall not be considered confidential if it does not provide information to allow identification

of individual patients.

Release of information regarding conditions that include genetic testing, alcohol/substance abuse, mental health, abortion, sexually transmitted disease,

and HIV/AIDS require a special member signed authorization, separate from a general authorization, and will be released only in accordance with Federal or State laws, court orders, or subpoenas.

MPCS will provide individuals with access to their PHI. Members or their

representatives are provided with access to their PHI as required per HIPAA. Also, members have the right to specifically authorize or deny a release of information for uses beyond treatment, payment, or health care operations.

All member medical records will be maintained for 10 calendar years, and in the

case of a minor, for 4 years after the enrollee reaches the age of majority (18 years of age) or 7 years after the date of the service, whichever is longer.

Claims payment and referral information that may disclose the member’s

condition may be given to the member (or designee) in a timely manner upon request. Only payment and referral information that does not disclose the member’s condition or reason for seeking medical care may be given to persons

who have been properly identified as the member’s family members or friends,



and only after sufficient proof of their involvement in the member’s care has been provided.

MPCS will inform any client plans if inappropriate use of the information occurs.

MPCS shall inform the health plan of the inappropriate use or disclosure of protected health information required per HIPAA.

MPCS shall ensure that PHI is returned, destroyed or protected if the delegation agreement ends required per HIPAA.

Tracking Mechanism

UM staff use designated software systems to track the utilization review process in its entirety, which includes documentation of confidential information used to make

utilization review determinations. MPCS also uses designated software to track the review and attestation to all corporate policies and procedures on confidentiality.

Oversight

The Chief Medical Officer , in collaboration with UM management and other appropriate

MPCS leadership, is responsible for ensuring the UM department’s adherence to MPCS ’ confidentiality policies and procedures during UM decision making and UM program

activities.



MPCS 13 Technology Evaluation and Medical Policy for UR Determination

Policy Statement

The purpose of this policy is to ensure medical policies and protocols on new medical technologies and/or new applications of existing medical technologies are developed and

maintained in accordance with state and federal regulatory requirements, and contract definitions of medical appropriateness and experimental/ investigational procedures. This process is reviewed at least annually and any necessary changes made accordingly.

For the purpose of this policy, medical technologies are defined as procedures,

treatments, supplies, devices, equipment, services and/or medications. Technologies are considered to be experimental/investigational when they do not have final approval from the appropriate governmental regulatory bodies, or the scientific evidence does not

permit conclusions concerning the effect of the technology on health outcomes, or they do not improve the net health outcome, or they are not as beneficial as any established

alternatives, or the improvement is not obtainable outside the investigational setting. Some examples of experimental/investigational technologies include rugs or devices that lack final FDA approval but have been approved for investigational purposes, or novel

technologies and modalities.

Further, medical protocols are defined as a combination of administrative and medical appropriateness information that help clarify coverage of services based on interpretation of member contracts and may include procedures, treatments, supplies, devices,

equipment, and/or medications. Examples of services that may be included in a medical protocol are durable medical equipment, criteria for coverage of clinical trials, NYS mandates, and therapies.

Procedure

1. Sources that identify the need for technology review may include new state or federal changes or requirements, internal or external requests, published literature, provider feedback or requests, Community Technology Assessment and Advisory Board

(CTAAB) recommendations, and technology evaluation reports.

2. Once the need for technology review is identified, the evaluation process may consist of reviewing information from appropriate government regulatory bodies, published scientific evidence, relevant specialists and professionals with expertise in the

technology or subject area, and any client health plan technology evaluations that include the above elements. MPCS will obtain information regarding an issue under

review from multiple sources that may include (but are not limited to) current scientific literature published in peer review journals and periodicals, BCBSA Technology Evaluation Center assessments, Food and Drug Administration (FDA),

Centers for Medicare and Medicaid Services (CMS), CTAAB, board certified physicians within MPCS , non-physician health care practitioners, other formal



assessments (e.g. Office of Health Technology Assessment (OHTA), and additional sources including clinical practice guidelines, manufacturer’s literature, and internal

criteria.

Variables customarily considered in, but are not limited to, the development of medical policies include appropriateness of issues being addressed, credibility of authors and sources utilized, timeliness of the documented literature,

comprehensiveness of the policy, application to contract/benefit packages, and market place demand including m ember and/or provider complaint or recommendations.

Moreover, the technology must have final approval from the appropriate governmental regulatory bodies, the scientific evidence does not permit conclusions concerning the effect of the technology on health outcomes, the technology improves

the net health outcome, the technology is at least as beneficial as any established alternatives, and the improvement is obtainable outside the investigational setting.

3. MPCS then implements and disseminates new (or changes to existing) medical

policies and protocols to all affected staff and providers. As such, affected personnel

receive training on new and/or revised criteria once approved for use. Criteria is then made available in both paper and electronic formats for ease of access. Providers are

notified of new or revised criteria through MPCS ’s bulletins, newsletters, and website.


MPCS ’ CMO, in collaboration with UM management, are responsible for tracking and

oversight of the requirements outlined in this policy.



UM 14 Continuity of Care

Policy Statement

MPCS has processes for members to continue a course of treatment with a provider who may become non-participating for a limited time and under the following circumstances:

Existing members who are engaged in a course of treatment with a provider that

leaves the network may continue treating with said provider for 90 days after receiving notification of the provider’s departure, unless the provider was terminated for reasons related to threat of imminent harm to members, fraudulent

conduct, or has been the subject of a final disciplinary action by a state licensing board or other governmental agency that impairs the practitioner’s ability to

practice.

Existing members who are in their second trimester of pregnancy and engaged in

a course of treatment with a provider that leaves the network may continue treating with their non-participating provider through delivery and post-partum

care directly related to that delivery, unless the provider was terminated for reasons related to threat of imminent harm to members, fraudulent conduct, or has been the subject of a final disciplinary action by a state licensing board or other

governmental agency that impairs the practitioner’s ability to practice.

New members that transition into the client health plan who are undergoing a course of treatment for a life-threatening and/or disabling and degenerative

disease may continue treating with their non-participating provider who is caring for their condition for 60 days from the date of their enrollment.

New members that transition into the client health plan who are in their second trimester of pregnancy may continue treating with their non-participating provider

through delivery and post-partum care directly related to that delivery.

In all of the above instances, the provider must agree to accept the established rates of the client health plan , meet the client health plan’s quality standards, provide all necessary information related to the member’s care, and agree to adhere to all relevant policies and

procedures of the client health plan, which include but are not limited to precertification, referral, and quality assurance requirements. Transitional coverage is for those services

contained in the member’s contract, and are subject to described limitations.

Procedure



1. UM will accept continuity of care referral requests from both members and

providers per the above policy statement. A UM decision will be made following standard protocol for making utilization review determination on service requests.

Medical Directors are available for consultation as appropriate, and in cases of adverse determinations. Note that continuity of care requests can be denied if not considered to be medically necessary during the utilization review process.

2. Notice of determination will be sent to the member and provider following the

processes outlined in policy titled UM 2-UM Determination and Notification Requirements.

3. When continuity of care requests are approved, the non-participating provider must sign and return a letter of agreement that clearly states the provider’s

requirement to follow the policies, procedures, requirements and fee schedule of the client health plan. This letter of agreement will be generated from, and returned to the Provider Relations department.

Tracking Mechanism


Oversight


oversight of this policy



MPCS 15

Emergency Services

Policy Statement

An emergency condition is a medical or behavioral condition the onset of which is

sudden, which manifests itself by symptoms of sufficient severity, including severe pain that a prudent layperson possessing an average knowledge of medicine and health could reasonably expect the absence of immediate medical attention to result in:

placing the health of a person afflicted with such condition in serious jeopardy, or

in the case of a behavioral health condition, placing the health of such person or others in serious jeopardy,

serious impairment of such person’s bodily functions,

serious dysfunction of any bodily organ or part of such person, or

serious disfigurement of such person.

Procedure

There are no prior authorization requirements for emergency services, and nor will reimbursement for such services be denied on retrospective review, regardless of whether

the provider is participating or non-participating with MPCS , providing the emergency services were medically necessary to stabilize or treat an emergency condition. . Prior

notification of the provision of emergency services is not required. Emergency services include inpatient and outpatient health care procedures, treatments or services that are furnished by a provider qualified to furnish these services and that are needed to evaluate

or stabilize an emergency medical condition including psychiatric stabilization and medical detoxification from drugs or alcohol. Emergency services also include Screening,

Brief Intervention, and Referral to Treatment (SBIRT) for chemical dependency.

Tracking Mechanism

Claims data is available for tracking purposes as needed.

Oversight




MPCS 16

UM Out-of-Network Requests

Policy Statement MPCS has a process in place for members to utilize out-of- network (or out of area)

providers when their health care needs extend beyond the capacity of the current network. Out-of-network requests require prior approval, except in cases of emergency (which is further defined in policy titled MPCS 15- Emergency Services). No emergency services

require prior authorization.

Types of out-of-network requests may include experimental/investigational treatment, specialty care with providers or centers, second opinions, standing referrals, a request for a specialist as a coordinator of primary care, a continuation of existing relationships for

diagnosis and treatment of a rare disorder, and any other services identified by the client health plan as having referral, prior approval, or utilization review requirements.

Additionally, out-of-network requests may be inpatient or outpatient, prospective, concurrent, retrospective, urgent or non-urgent. Such services are reviewed by staff comprised by medical directors (also known as physician reviewers), physician-level

clinical peer reviewers, registered nurses, licensed social workers, and licensed practical nurses with current, valid, and unrestricted licenses. Refer to policy titled MPCS 11-

Utilization Management Personnel for full job descriptions and reviewer accountabilities. Procedure

1. UM staff follow standard review protocols and reference appropriate criteria for evaluating all service requests that are subject to the UR process. Benefit

coverage is first assessed through internal systems and processes in accordance to New York State (NYS) contracts and coverage guidelines. Utilization reviewers

who are registered nurses, licensed master level social workers, or licensed practical nurses trained in the principles and practices in utilization review may contractually deny cases (that are within their respective scopes of practice) as not

meeting established benefit criteria; although involvement of physician reviewers may be considered in instances where recommendation is made to approve

services beyond the benefit limitation if it is in the best interest of the member.

2. If benefit coverage is met, all available and necessary relevant clinical

information, including medical records, are obtained prior to the review to enable the utilization reviewer to make an appropriate determination regarding services

requested. Information obtained for utilization review decisions come from many sources. The amount and/or type of data required to make a utilization review determination depends on the circumstances of the case. Written and/or

verbal information may be obtained from a member’s primary care physician, or any specialist, ancillary, or institutional provider involved in the member’s care.



Collected information is then reviewed against established criteria and guidelines to make utilization review determinations. MPCS maintains procedures on data

sources that may be gathered for UM decision making, and standards for documenting the request, receipt, processing, and storing of such data. Data

sources that may be gathered for UM decision making may include, but are not limited to office and/or hospital records that may include a history of illness, psychosocial issues, diagnostic testing results, clinical exams, treatment plans,

and progress notes, evaluations from and conversations with applicable health care providers, photographs, operative and pathological reports, rehabilitation

evaluations, criteria and benefits related to the service request, information on the local delivery system, patient characteristics and information, information from responsible family members, letters of medical necessity, applicable health plan

contracts, and applicable federal and state benefit guidelines. See policy titled MPCS 10-Collection and Documentation of Relevant Information for additional

information about the collection and documentation of information used in the utilization review process.

3. Essentially, out-of-network reviews are a two-tiered process. UM will first review for clinical necessity of the service request, followed by a review of

providers in-network with the appropriate expertise and training that meet the member’s health care needs.

Clinical necessity criteria is then applied in a hierarchy fashion that begins with New York State coverage (NYS) criteria. In instances where NYS coverage

criteria is not available, MPCS follows the least restrictive criteria available. Detailed descriptions on all criteria sets can be found in policy titled MPCS 03- UM Review Criteria and Criteria Availability.

Ensure documentation is clear in referencing that the out-of-network request was

reviewed for clinical necessity, and the outcome of such review.

Please note that medical necessity criteria are intended to be used as guidelines,

and are not intended to replace appropriate clinical judgment. Adaptation of these guidelines may be necessary based on individual needs such as age,

comorbidities, psychosocial factors, home environment, and treatment progress. Characteristics of a patient’s local delivery system are also considered when determining medical necessity. The resultant decision will be based in part on a

review of relevant clinical information such as medical records, objective and evidence based criteria, evaluation of received medical opinions, and any other

relevant clinical information. This could also include the medical opinion of a professional society, peer review committee, or other groups of physicians. Services are considered medically necessary when they are appropriate and

consistent with the diagnosis and treatment of a patient’s medical condition, are required for the direct care and treatment or management of that condition, the

condition would be adversely affected if the requested services are not/were not provided, are provided in accordance with community standards of good medical



practice, are not(primarily)for the convenience of the patient, the patient’s family, the professional practitioner, or another provider, are the most appropriate service

for the condition, are rendered in the most efficient and economical level of care which can safely be provided.

The utilization review in its entirety, as well as any referrals made to other departments for quality of care or case management issues identified during the

utilization review process, is recorded in the designated software systems in accordance to standard UM documentation guidelines. Please note that all out-of-

network requests are referred to case management for assistance.

4. Once the clinical necessity portion of the review is complete, the case is then

researched for in-network providers reasonably located within the member’s geographical area that possess the appropriate training and experience to meet the

member’s health care needs. A minimum of two such providers are contacted by the UR agent to confirm availability. The provider’s contact information and their availability is then recorded in the designated software system in accordance

to standard UM documentation guidelines.

5. All out-of-network requests are then routed to the medical director (MD) for review. Only board-certified physicians reviewers, also known as Medical Directors or Clinical Peer Reviewers, with current, valid, and unrestricted licenses

trained in the principles of practices of utilization review, and with no previous involvement in the member’s health care, may issue adverse determinations

If the utilization reviewer assesses and documents the services as medically appropriate, the MD is asked to assess whether the in-network providers identified

possess the appropriate training and experience to meet the member’s health care needs. If yes, than the request may be denied as services available in-network

(Not a Covered Benefit). If no, than the request may be authorized.

If the utilization reviewer assesses and documents the services as not medically

necessary, the MD is asked to assess whether the services are medically appropriate to approve. If not medically appropriate, than the medical director

may deny the request as not medically necessary. However, if medically necessary, the MD will then determine whether the in-network providers identified possess the appropriate training and experience to meet the member’s

health care needs. If yes, than the request may be denied as services available in-network (Not a Covered Benefit). If no, than the request may be authorized.

The MD will document the outcome of his/her review in the designated software system using standard UM documentation guidelines, and return the case to the

utilization reviewer for completion.

6. Notifications of the decision are issued to all relevant parties in accordance to the requirements outlined in policy titled MPCS 02- UM Determination &



Notification Requirements, and all such activity will be captured by the utilization reviewer in the designated software system. Please note, for requests denied due

to services available in-network, the verbal notice to the provider(s) and member must also include a discussion about the availability of in-network providers to

meet the member’s needs. Also, for actions based on a determination that a requested out-of-network services not materially different from an alternate service available from a participating provider, the notice of action shall also

include a description of the alternate service that is available in network and how to access the alternate service or obtain authorization for the alternate service ( if

required by MPCS ), notice of the required information that must be submitted when filing an action appeal for MPCS to review the medical necessity of the requested service [as provided for in PHL 4904 (1-a)], a statement that if the

action appeal is upheld as not medically necessary, the member may be eligible for an external appeal. If MPCS will not conduct a utilization review appeal in

the absence of the information described in PHL 4904 (1-a), a statement that if the required information is not provided, the action appeal will be reviewed by MPCS but the member will not be eligible for an external appeal, a statement that

if the action appeal is upheld as not medically necessary, the member will have four (4) months from the receipt of the final adverse determination to request an

external appeal, a statement that the member and MPCS may agree to waive the internal appeal process, and the member will have four (4) months to request an external appeal from receipt of written notice of that agreement, and a statement

that if the member files an expedited action appeal for review of the medical necessity of the requested service, the member may request an expedited external

appeal at the same time, and a description of how to obtain an external appeal application.

Tracking Mechanism

UM staff use designated software systems to track the utilization review process in its

entirety.

Oversight




MPCS 19 UM Quality Improvement Initiatives

Policy Statement

The overall quality and effectiveness of the UM Program is evaluated and reported to MPCS ’ Quality Committee at least quarterly throughout the year using multiple

measures. The UM dashboard is a living document that serves as a tool for reporting quality, compliance, and performance measures that include utilization review volume & time frames data, case management referral volume, care coordination volume, UR

trends, provider & member satisfaction surveys, and quarterly inter-rater reliability audit scores to the Quality Committee and to the client health plan. Monthly audits of

individual UR charts, member and provider complaint data, and staff performance appraisals also assist in evaluating program effectiveness, but are tracked separately from the UM dashboard and are overseen by UM management.

All such measures are designed to ensure that utilization review activity are functioning

at a level that help maintain, restore, or improve health outcomes of individuals and populations. Below is a summary of how each measure is calculated and benchmarked for reporting purposes and improvement opportunities.

Procedure

UM Volumes

& Time Frame Data

Ensuring that time frames set forth by state, federal, & accreditation

bodies are met is critical to the utilization management process.

Timeframe adherence ensures that a prompt and timely decision is

made on requests, and minimizes unnecessary and arbitrary wait

times that may be encountered by providers who require services in

a timely fashion. Adherence to this principle helps ensure that the

right care is delivered at the right time. Tracking UM volumes is

essential to ensuring there are adequate staffing resources available

to manage all service requests received in the department within

required time frames. Monthly time frame percentages are

calculated and reported upon by dividing the number of cases

identified out of time frames per month by the total number of

reviews received in the department per month. No more than 5% of

reviews received in the department per month must be processes out

of time frames. With regards to UM volumes, all fully trained

utilization reviewers are assigned no less than 10 reviews per day of

various degrees of complexity by the UM Triage & Training

Coordinator. This role is primarily responsible for the equitable

distribution of utilization reviews among the UM staff in

accordance to review priority and complexity to ensure that

individual productivity requirements and departmental time frame

metrics are tracked, met, and maintained on a daily basis. All UM

reviews from intake are checked for errors by the Triage

Coordinator. Identified errors are corrected prior to triaging, which

enables UM reviews to be processed more efficiently. Errors are

formally documented on a shared error report and sent back to

intake for monitoring, tracking, and coaching.



Case Management (CM)

Referral Volume

This measure captures UM’s ability to accurately refer members

who meet specific triggers to case management. Monthly referral

numbers are provided to UM by the case management department.

To calculate the percentage of cases appropriately referred to the

CM department, the number of UM referred cases that are referred

for CM or outreach is divided by total number of UM referred

cases.

Care Coordination Volume

The utilization review process provides opportunities for UM staff

to identify members who may benefit from care coordination. The

care coordination model offers support, education, and resources

relating to the condition(s) in which members are receiving

treatment for, collaborates with members and providers to

eliminating barriers to treatment, promotes engagement with

medically appropriate levels of care, and encourages members to

participate in one of MPCS ’ programs such as Case Management

services as appropriate.

Trend Analysis

Trend analysis is another process utilized to evaluate the

effectiveness of the UM program. Trends analyzed include, but are

not limited to denial volume, volume of cases overturned on appeal,

and over and under- utilization of services. For example, identifying

the volume of cases overturned on appeal is an especially helpful to

ensuring quality within the initial level utilization review process.

This volume is determined by obtaining the percentage of cases

overturned without new or additional information within a given

time period from the appeals department. The historical benchmark

goal is to maintain that no more than 5% of denial conducted by the

utilization review department are overturned on appeals.

Results of all trend analysis initiatives are evaluated for

strengths and improvement opportunities. Designated

staff are appointed to design, implement, and monitor

interventions against benchmarks to determine areas

where corrective action is required. Results and

interventions are then reported to UM Quality

Committee for review.

Member & Provider

Satisfaction Surveys

Member and provider satisfaction surveys are conducted on an

annual basis to determine overall satisfaction with the utilization

review process.

To summarize, data collected from the biannual New York State

Department of Health sponsored Consumer Assessment of

Healthcare Providers and Systems (CAHPS) survey is used to

measure member satisfaction from a sampling of enrollees.

Majority of CAHPS survey questions are designed to solicit

feedback from members on their experiences with access to health

care, health care providers, and health plans, which are important

indicators of an enrollee’s satisfaction with UM related activities.

Response options for overall rating questions ranged from 0 (worst)

to 10 (best). Plan level results are compared to the statewide results

for statistical significance and are presented with statewide, New

York City (NYC), rest of state, as well as individual plan results.

Regional results are presented for additional information, but are

not compared to the statewide achievement scores.



Provider satisfaction is measured with data collected from a

telephonic survey that is designed and implemented by designated

UM staff. Providers are asked a series of questions with regards to

their overall satisfaction with the utilization review process for

which answers are given in yes or no format, or a five-point Likert

scale format. Every question (or measure) of the survey is scored

by dividing the number of response received per answer category

by the total number of providers who responded to the question

being scored. For measure with a yes/no format, the historical

benchmark is to achieve 90% of yes answers. For measures with a

Likert scale format, the historical benchmark is to achieve a

combined total of 90% on answers that include Strongly Satisfied or

Satisfied.

Both survey results are shared with the UM department.

Designated staff are appointed to design, implement, and monitor

interventions for areas where corrective action is required. Results

and interventions are then reported to the UM Quality Committee

for review.

Inter-Rater Reliability Audits

Inter-rater reliability audits are conducted on a quarterly basis to

ensure that UM staff and Medical Directors are consistently

applying criteria used to make pre-service, concurrent, and post-

service utilization review determinations for both inpatient and

outpatient services.

This methodology ensures consistency measures required of the

UM decision making process are monitored throughout the year,

and opportunities for individual and/or team development

opportunities are implemented as needed.

For each inter rater audit, UM Quality staff applies the procedure

commonly referred to as the NCQA “8/30 methodology” file

sampling procedure. The procedure involves randomly selecting a

sample of 8 completed UR cases. The principles apply to the

universe of health care organizations that the NCQA accredits. If

any of the 8 cases fall outside the standards that NCQA requires for

file review, than an additional random sample of 22 UR cases are

reviewed, totaling 30 cases.

Detailed results are then shared with the department. Remediation is

conducted on all cases where 100% inter- rater reliability is not

achieved. Findings and interventions of inter-rater reliability audits

are reported to the MPCS QM Committee at least annually.

The CMO oversees the administration of inter-rater audits to the

physician review staff. Physician review staff complete no less than

inter-rater audits on a yearly basis, and the same process noted

above is followed for facilitation of the inter-rater audits, scoring,

and remediation.

UR Chart Audits

Chart auditing is essential to ensuring compliance to

state, federal, accreditation, and internal policies and

procedures on utilization review chart documentation

standards, letter requirements, review criteria, and



review priority. Two utilization review charts are

randomly selected and audited per month per reviewer.

Each chart is audited using standardized form with

questions that measure compliance to the above noted

areas. Individual and aggregate scores are analyzed for

strengths and development opportunities. Chart audit

scores are shared with UM staff during mid-year and

year-end performance valuations, and also on an ad-hoc

basis as needed. Staff are required to achieve no less

than 90% accuracy per chart reviewed, with an average

of 90% per month.

Member and Provider

Complaints

Utilization Management investigates complaints as they arise.

MPCS uses the definition of a grievance as outlined in New York

State Public Health Law 42 CFR 438.488 as a guideline for what

constitutes a compliant, but specific to actions or behaviors of the

UM department. Complaint are taken very seriously because it

represents that an event transpired for which an individual deemed

important enough to inform our organization. All complaints are

addressed in a timely fashion, and by the most appropriately

qualified staff person based on the nature of the complaint.

Complaints shall be analyzed to determine opportunities to improve

internal processes and/or relations with external entities. The

benchmark is to achieve no less than 10 complaints per calendar

year. Results and interventions are reported to UM Quality

Committee for review and feedback.

Performance Appraisals

The performance of every UM staff member is evaluated twice

annually using MPCS Human Resource policies and procedures.

Preferable outcomes for the annual evaluation are Exceeds

Expectations or Achieved Expectations. Staff development is

conducted continuously throughout the year.

Tracking Mechanism


ensuring that the UM program is reviewed at least on an annual basis, and findings are presented to the Quality Committee for review, feedback, and approval.

Oversight





MPCS 20 UM Clinical Peer Reviewers

Policy Statement

Clinical peer reviewers are available to provide MPCS UM personnel with medical recommendations to assist in the utilization review process on a case by case basis.

Clinical peer reviewers are board-certified physicians with current, valid, and unrestricted licenses. MPCS multiple specialties to perform clinical peer review services. See policy

titled MPCS 11- Utilization Management Personnel for a list of independent practitioners and vendors who offer clinical peer review services. Procedure

1. A member of MPCS UM management (listed below) is contacted to initiate the clinical peer review process when the need for clinical peer review services is

identified. The use of clinical peer review services are generally requested at the discretion of MPCS medical directors.

UM Manager

UM Supervisor

UM Training & Triage Coordinator

All other staff designated by UM Management team

2. Designated MPCS UM staff are then instructed to prepare the case for clinical

peer review. a. Preparation involves collecting all appropriate clinical information (see policy

titled MPCS 10-Collection & Documentation of Relevant Information for additional details on collection of information as it relates to the UR process),

and if applicable, the criteria for which the clinical information is to be reviewed against.

b. The specialty of the clinical peer reviewer is determined by the specialty of the service requested. UM time frames requirements still apply in instances

where clinical peer reviewers are consulted for feedback during an active utilization review. The UM case may be pended in accordance to standard UM protocols as outlined in the policy titled MPCS 02- UM Determination &

Notification Requirements to await the outcome of the clinical peer review if it is in the best interest of the member.

3. The clinical peer reviewer will complete and forward their medical

recommendations regarding the service request within the time frame requested

by MPCS . The recommendations are forwarded to the requesting medical director. A decision on the service request is then made by the medical director,



and the case is returned to the utilization review agent for completion following standard UM protocols outlined in policy titled MPCS 02- UM Determination &

Notification Requirements.

Tracking Mechanism


Oversight




MPCS 21 UM Pharmacy Management

Policy Statement

MPCS (MPCS) provides oversight of UM functions for YourCare Health Plan (YCHP). YCHP pharmacy benefit includes a formulary that is designed to offer cost-effective

health care to the members it serves. YCHP has delegated its pharmacy benefits management to Express Scripts (ESI). This policy sets forth the framework under which YCHP manages its pharmacy benefits through ESI, the activit ie s of the YCHP

Pharmacy and Therapeutics (P&T) Committee, and the formulary used.

This policy is applicable to all formularies offered by YCHP for pharmaceutical and related products, regardless of line of business, unless otherwise noted. This policy shall apply to all YCHP plans and employees, as well as all P&T Committee members

and invitees.

Procedure

ESI is responsible for the following PBM activities: Through its National P&T Committee, ESI will review the formulary on an

ongoing basis and makes recommendations for updating the YCHP formulary (additions and deletions of therapeutic agents and expansion of appropriate

indications). Monitoring for FDA new drug approvals and new clinical indications. Implementing and maintaining the YCHP formulary according to YCHP criteria.

Providing recommendations to YCHP regarding Prior Authorization (PA), Step-Therapy (ST), Quantity Limit (QL), and non-formulary coverage criteria.

Managing the drug utilization process including PA, ST, QL, and non-formulary request review.

Providing utilization management activities for specialty pharmacy drugs.

Maintains pharmacy website portal for members and providers. Adhering to New York State Department of Health (NYSDOH) regulations as it

relates to the Utilization Review (UR) process. Adhering to National Committee for Quality Assurance (NCQA) requirements as

it relates to the UR process.

Reporting performance routinely to YCHP in accordance with contractual agreements.

The Appeals/Grievance processes will remain the responsibility of YCHP as will utilization management for drugs that are paid under the medical benefit and not reviewed specifically by ESI.

Committee Oversight:

MPCS’ Utilization Management Committee will report on the pharmacy management program to senior management on a routine basis to support vendor

oversight activities. It will review ESI performance and make recommendations to senior management regarding the relationship between ESI and YCHP.



ESI will provide the YCHP P&T Committee with the minutes from its ESI

National Pharmacy and Therapeutics Committee. These minutes and its recommendations will be reviewed by the YCHP P&T Committee. The YCHP P&T Committee will then approve or modify the ESI P&T Committee’s

recommendations for implementation by ESI in the management of YCHP’s pharmaceutical management. Any criteria that would require a significant change

in health plan medical policy will be reviewed by MPCS’ Medical Policy Committee, prior to implementation by ESI. The YCHP P&T Committee will meet approximately 6 weeks after the ESI P&T Committee has its meeting.

The ESI P&T Committee consists of, but not limited to, a panel of Board Certified physicians and pharmacists in the fields of:

Allergy and Immunology Cardiology Critical Care Medicine

Dermatology Endocrinology

Gastroenterology Geriatrics Pharmacy Geriatrics

Internal Medicine Obstetrics and Gynecology

Oncology Ophthalmology Pediatrics

Psychiatry Pulmonology

Rheumatology Other specialty physicians are invited on an ad hoc basis to provide input on

more complicated conditions/issues under discussion.

The YCHP P&T Committee consists of: 1. YourCare CMO (Internal Medicine), Chair

2. Psychiatrist 3. Pharmacist (Pharm.D) 4. Utilization Review Manager

5. Pharmacist representatives from ESI 6. Other specialty physicians/expert specialty reviews may be included on an as

needed basis.

Formulary Principles: YCHP develops and maintains its formulary based on guiding

principles that reflect 6 goals (safe, timely, effective, equitable, efficient and patient centered). These principles are prioritized in descending order (i.e. effectiveness is

weighted most heavily, followed by safety issues, and then by cost). Formulary decisions are made following a careful review of the often‐competing principles as

listed below. Proven effectiveness documented in the medical literature: The primary

consideration will be the degree to which a medication produces clinically



desirable effects. Beneficial effects are assessed on the strength of scientific evidence including peer‐ reviewed medical literature, pharmacoeconomic

studies, and outcomes research, and standards of practice including treatment

protocols and evidence‐based practice guidelines. Randomized, controlled trials are weighted most heavily, followed by non‐randomized trials, case

reports, and medical opinion. Maximizing safety and minimizing the potential for errors: The safety

risk / benefit of a product will be compared with other treatments. YCHP will minimize the potential for errors caused by product characteristics such as

name, dosage form, and packaging that pose threats to patient safety or increase the potential for errors in the health care system.

Optimizing pharmacoeconomics: The overall value of a drug or therapy

will be compared with existing treatments to assess pharmacy costs in relation to medical outcomes. YCHP will consider direct and indirect

pharmacy and medical costs and will take into consideration and give preference to those agents that optimize the use of financial and service resources over the largest potential population.

Emphasis on products essential to health: Significant improvements in patient convenience, adherence, and satisfaction. YCHP will review more

favorably products that have significant improvements in patient convenience, adherence, and satisfaction. Examples include variables such as dosing convenience, variety of dosage forms, taste, ability to crush or divide

doses, and storage requirements (refrigeration). Long term stability of formulary decisions: Changes to the formulary will

be minimized for member care continuity. The formulary will serve as a guideline for the vast majority of patients.

1. Utilization management programs such as prior authorization, step‐edits, MD‐edits, quantity limits, and age limits will be applied to promote appropriate

utilization. 2. A “Formulary Exception” process will be readily available, easy to use, and

timely.

3. A “Transition of Care” policy will be available to assist members transitioning to YCHP.

Tracking Mechanism

In addition to ESI providing routine reports to YCHP as contractually required, MPCS

will conduct a file review of ESI pharmacy denials on a quarterly basis using NCQA’s 8/30 file review methodology and worksheet.

In the event that ESI fails to meet established performance thresholds, ESI must submit and implement a corrective action plan. Audit findings will be reported to MPCS’

Utilization Management Committee and senior management as part of vendor oversight activities.

Oversight

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