SMMCAC Complaints, Appeals, and Fair Hearings Subcommittee ...
37
SMMCAC Complaints, Appeals, and Fair Hearings Subcommittee Meeting Friday, June 26 th , 2020 Rev: 8/10/2020
Transcript of SMMCAC Complaints, Appeals, and Fair Hearings Subcommittee ...
SMMCAC Complaints, Appeals, and Fair Hearings Subcommittee
MeetingFriday, June 26th, 2020
• Proposed Process for MDCP & Star Plus
• General Assumptions
• Roundtable
2
• Required by Senate Bill (SB) 1207, 86th Legislative Session
• The commission shall contract with an independent external medical reviewer to conduct external medical reviews
3
Background - External Medical Reviewer
External Medical Reviewer is a third-party medical review organization, or an Independent Review Organization, that provides objective, unbiased medical necessity determinations conducted by clinical staff with education and practice in the same or similar practice area as the procedure for which an independent determination of medical necessity is sought in accordance with applicable state law and rules.
4
Independent Review Organization to review:
• The resolution of a Medicaid recipient appeal related to a reduction in or denial of services on the basis of medical necessity in the Medicaid managed care program;
• Denial by the commission of eligibility for a Medicaid program in which eligibility is based on a Medicaid recipient’s medical and functional needs.
5
Qualifications for contracted Independent Review Organization
• Medicaid managed care organization may not have a financial relationship with or ownership interest in the external medical reviewer with which the commission contracts.
• Must be overseen by a medical director who is a physician licensed in this state
• Must employ or be able to consult with staff with experience in providing private duty nursing services and long-term services and supports.
6
• To the greatest extent possible, the procedure must reduce administrative burdens on providers and the submission of duplicative information or documents.
• Medical necessity under the procedure must be based on publicly available, up-to-date, evidence-based, and peer-reviewed clinical criteria.
7
Background – Review Period
• The reviewer shall conduct the review within a period specified by the commission.
• The commission shall also establish a procedure and time frame for expedited reviews that allows the reviewer to:
• Identify an appeal that requires an expedited resolution
• Resolve the review of the appeal within a specified period.
8
Background – Request for Review
• Medicaid recipient or applicant, or the recipient’s or applicant’s parent or legally authorized representative, must affirmatively request an external medical review.
• If a review is requested the review occurs after…
• The internal Medicaid managed care organization internal appeal and before the Medicaid fair hearing and is granted when a Medicaid recipient contests the internal appeal decision of the Medicaid managed care organization
• The eligibility denial and before the Medicaid fair hearing.
9
Background - Medical Necessity
• The external medical reviewer’s determination of medical necessity establishes the minimum level of services a Medicaid recipient must receive, except that the level of services may not exceed the level identified as medically necessary by the ordering health care provider.
• The external medical reviewer shall require a Medicaid managed care organization, in an external medical review relating to a reduction in services, to submit a detailed reason for the reduction and supporting documents.
10
Background - Prior Authorization
To the extent money is appropriated for this purpose, the commission shall publish data regarding prior authorizations reviewed by the external medical reviewer, including the rate of prior authorization denials overturned by the external medical reviewer and additional information the commission and the external medical reviewer determines appropriate
11
Includes:
• Managed Care Benefit Reduction or Denials for Managed Care Organizations (MCOs), Dental Maintenance Organizations (DMOs).
• Includes pharmacy benefits.
• Eligibility denials for the Medically Dependent Children’s Program waiver and STAR+PLUS Home and Community Based Services waiver based on medical necessity
• Certain Medicaid Waiver populations
Ongoing Work
• Amending HHSC and MCO member notifications to include Fair Hearing and EMR information
• When appropriate, leveraging the editing process to standardize language and increase plain language
• Survey in July 2020 will include PDFs of the notices and provide stakeholders the opportunity to provide input on their clarity
Ongoing Work (continued)
• Development of rules
• Implement MCO contract changes
External Medical Review MCOs/DMOS
15
The EMR process occurs within the Fair Hearing timeline
16
Fair Hearing and EMR Timelines
A “regular” Fair Hearing is a non-emergency Fair Hearing and is completed within standard processing timeframes. The standard processing timeframe for MCO-related Fair Hearing decisions is 90
days from the date the MCO internal appeal is requested, not including the number of days the member takes to request the fair
hearing after the MCO internal appeal is completed.
17
Fair Hearing and EMR Timelines (continued)
An emergency Fair Hearing is a Fair Hearing which meets expedited criteria. Expedited criteria is met when the MCO determines or the
provider indicates taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function. Emergency Fair Hearings must be
completed within 3 business days from the date the MCO provides information indicating the expedited criteria is met.
18
EMR Key Takeaways
• The timeframe to request a State Fair Hearing does not change.
• The requirements for continued benefits does not change.
• The requirements for an emergency appeal do not change.
• The Member must exhaust the Internal MCO Appeal prior to requesting a State Fair Hearing and EMR.
19
EMR Key Takeaways (continued)
• The member or MCO or DMO may not submit additional information to the IRO.
• Changes in condition or new information should be submitted to the MCO or DMO.
• If the Member or MCO or DMO requests, the IRO must attend the State Fair Hearing.
20
End User Training Module Specifics
• The EUT process will occur in both phases of the IRO project
• Phase I – Development and Deployment
• Phase II – Refinement and Maintenance
• The training modules will provide a comprehensive overview of the Medicaid programs, benefits and eligibility, supports, resources for the external medical review and independent medical review organization process to external and internal stakeholders as related to the fair hearings and member appeals process.
21
End User Training Module Specifics (continued)
• All identified external and internal stakeholders will complete a mandatory initial training and complete an attestation to submit to HHSC as verification they are ready to conduct business on the operational start date.
• Targeted IRO/EMR Training Module Audiences
• External Audiences:
23
Modules Developed: • EMR Process • Program Overview • Medical Benefits
(amount, duration and scope)
• MCO Fair Hearing/ Appeals
4/1/2020 - 5/14/2020
Module Development
Module Pre Roll-out Process Goal – to obtain user feedback and user experience and aid in module finalization • Modules emailed to
internal stakeholders to complete and submit feedback to the workgroup-
8/1/2020 - 8/15/2020
Key Activities: • Conduct trainings with IRO
Vendors, MCOs, DMOs, TMHP and HHSC staff to ensure they are ready to begin completing EMRs on the operational start date
6/3/2020
Committee Approval Meeting • Identify who will maintain
website • Establish training Completion
First Website Progress Check
IRO/EMR Project Go-Live Date
24
Background
Key Policy, Concepts & Procedures
Client Notification Changes N/A
• Uniformed Managed Care Manual (UMCM) • Uniformed Managed Care Contract (UMCC) • Texas Administrative Code (TACT) • Texas Medicaid Provider Procedures Manual (TMPM) • Managed Care Webpages • Texas Medicaid & Healthcare Partnership TMHP Website
Module Example
26
• Establish Learner Requirements • Identify when does subsequent training need to be
conducted after initial training
• Develop an attestation process for stakeholders to verify completion of training prior to operational start date
• Website Development • Develop a website for the training modules. Both
internal and external stakeholders will have access
• Designate HHSC staff who will be responsible for maintaining the website and updating the training modules to ensure consistency with latest policy, benefits and services.
Key Takeaways
• Each IRO stakeholder shall complete all of the end user training modules prior to the operational start date 9/1/2020.
• Each stakeholder organization will submit attestation documentation to HHSC as verification they have completed the modules and agree to abide by HHSC policy and procedures.
27
Key Takeaways (continued)
• All training modules will be maintained by HHSC and updated as necessary to ensure consistency with managed care policy, legislative and contractual information.
• The training module website will be utilized as a space to create a historical training library for stakeholders to utilize for reference .
28
Senate Bill 1207: Member Notice Requirements
Senate Bill 1207 mandated HHSC to ensure notices sent by HHSC or managed care organizations to a Medicaid recipient or provider regarding the denial, partial denial, reduction, or termination of a service to include:
• Information required by federal and state law and applicable regulations;
• Clear and easy-to-understand explanation of the reason for the decision; and
• An educational component that includes a description of the recipient's rights, an explanation of the process related to appeals and Medicaid fair hearings, and a description of the role of an external medical review
29
• Improve member understanding
• Enhance consistency of notices across MCOs and ensure they are compliant with regulatory requirements
• Incorporate the external medical review process
• Include MCO and HHSC contact information for Members who need assistance
30
Senate Bill 1207 – Revisions to Uniform Managed Care Manual, Chapter 3.21, Medicaid Managed Care Notices of Actions Required
• Notices are for service-level denials only
• PES has a different process for eligibility MN denials
• Two notices
• Notice 1 is sent at time of adverse benefit determination
• Notice 2 is sent after an MCO internal appeal
31
Senate Bill 1207 – Revisions to Uniform Managed Care Manual, Chapter 3.21, Medicaid Managed Care Notices of Actions Required (cont.)
• Each notice includes a letter, flyer, and form
• Letter - Details the adverse benefit determination
• Flyer - Explains appeal, external medical review, and fair hearing process
• Form - Allows the member to request an appeal, external medical review, and/or fair hearing 32
Member Notices: Current Steps & Upcoming
• Obtain stakeholder input on sample mock notices through a survey
• Submit UMCM 3.21 chapter revisions for internal routing – 6/30/2020
• Finalize and submit UMCM 3.21 – 7/15/2020
• Obtain MCO feedback through the UMCM contractual process
• New template effective in UMCM – 9/1/2020
33
• Member gets adverse determination
• Small mention of options after internal appeal
• Continuation of benefits
• Internal Appeal occurs between adverse determination and internal appeal decision
• Member Notice Content
• Continuation of benefits
• FH & EMR form
• Member gets EMR decision • If an External Medical Review is required it
occurs between internal appeal decision and EMR decision
• Member Notice Content • IRO Sends
• EMR evaluation outcome (sent to client, MCO & HHSC)
• Details on next steps for FH • Option to withdraw FH request, if any
• Member gets FH decision • If an External Medical Review is required a
Fair Hearing occurs between EMR decision and FH decision.
• If an External Medical Review is not required a Fair Hearing occurs between internal appeal decision and FH decision.
• Member Notice Content • HHSC Sends
• Standard existing fair hearing decisions
Appendix B - External Medical Review MDCP and STAR Plus HCBS - Text Explanation
• Individual gets adverse determination
• Provides an opportunity for the Member to provide additional information
• Individual gets final decision
• Member Notice Content
• Continuation of benefits
• FH & EMR form
• Individual gets EMR decision • If an External Medical Review is required it
occurs between internal appeal decision and EMR decision
• Member Notice Content • IRO/HHSC Sends
• EMR evaluation outcome (sent to HHSC)
• HHSC send Member outcome notice • Details on next steps for FH • Option to withdraw FH request, if
any
• Individual gets FH decision • If an External Medical Review is required a
Fair Hearing occurs between EMR decision and FH decision.
• If an External Medical Review is not required a Fair Hearing occurs between final decision and FH decision.
• Member Notice Content • HHSC Sends
• Standard existing fair hearing decisions
Appendix C - End User Training Key Milestones
• 04/01/2020 – 05/14/2020: Module Development • EMR Process, Program Overview, Medical Benefits (amount, duration and scope),
MCO Fair Hearing/Appeals
• 05/14/2020 – 06/03/2020: Module Pre-Rollout Period • Goal - to obtain user feedback and user experience and aid in module finalization.
Modules emailed to internal stakeholders to complete and submit feedback to the workgroup.
• 06/02/2020 – 07/31/2020: Website Development • Key Activities: HHSC Portal Steering Committee Approval Meeting, Identify who will
maintain website, Establish training Completion Attestation Process • 06/23/2020: First Website Progress Check • 07/05/2020: Training Module Schedule Notice • 07/14/2020: Second Website Progress Check • 07/28/2020: Training Module Website Preview
• 08/01/2020 – 08/15/2020: Initial Module Training Period • Key Activities: Conduct trainings with IRO Vendors, MCOs, DMOs, TMHP and HHSC
staff to ensure they are ready to begin completing EMRs on the operational start date
• 09/01/2020: IRO/EMR Project Go-Live Date
Structure Bookmarks
SMMCAC Complaints,
• Proposed Process for MDCP & Star Plus
• General Assumptions
• Roundtable
2
• Required by Senate Bill (SB) 1207, 86th Legislative Session
• The commission shall contract with an independent external medical reviewer to conduct external medical reviews
3
Background - External Medical Reviewer
External Medical Reviewer is a third-party medical review organization, or an Independent Review Organization, that provides objective, unbiased medical necessity determinations conducted by clinical staff with education and practice in the same or similar practice area as the procedure for which an independent determination of medical necessity is sought in accordance with applicable state law and rules.
4
Independent Review Organization to review:
• The resolution of a Medicaid recipient appeal related to a reduction in or denial of services on the basis of medical necessity in the Medicaid managed care program;
• Denial by the commission of eligibility for a Medicaid program in which eligibility is based on a Medicaid recipient’s medical and functional needs.
5
Qualifications for contracted Independent Review Organization
• Medicaid managed care organization may not have a financial relationship with or ownership interest in the external medical reviewer with which the commission contracts.
• Must be overseen by a medical director who is a physician licensed in this state
• Must employ or be able to consult with staff with experience in providing private duty nursing services and long-term services and supports.
6
• To the greatest extent possible, the procedure must reduce administrative burdens on providers and the submission of duplicative information or documents.
• Medical necessity under the procedure must be based on publicly available, up-to-date, evidence-based, and peer-reviewed clinical criteria.
7
Background – Review Period
• The reviewer shall conduct the review within a period specified by the commission.
• The commission shall also establish a procedure and time frame for expedited reviews that allows the reviewer to:
• Identify an appeal that requires an expedited resolution
• Resolve the review of the appeal within a specified period.
8
Background – Request for Review
• Medicaid recipient or applicant, or the recipient’s or applicant’s parent or legally authorized representative, must affirmatively request an external medical review.
• If a review is requested the review occurs after…
• The internal Medicaid managed care organization internal appeal and before the Medicaid fair hearing and is granted when a Medicaid recipient contests the internal appeal decision of the Medicaid managed care organization
• The eligibility denial and before the Medicaid fair hearing.
9
Background - Medical Necessity
• The external medical reviewer’s determination of medical necessity establishes the minimum level of services a Medicaid recipient must receive, except that the level of services may not exceed the level identified as medically necessary by the ordering health care provider.
• The external medical reviewer shall require a Medicaid managed care organization, in an external medical review relating to a reduction in services, to submit a detailed reason for the reduction and supporting documents.
10
Background - Prior Authorization
To the extent money is appropriated for this purpose, the commission shall publish data regarding prior authorizations reviewed by the external medical reviewer, including the rate of prior authorization denials overturned by the external medical reviewer and additional information the commission and the external medical reviewer determines appropriate
11
Includes:
• Managed Care Benefit Reduction or Denials for Managed Care Organizations (MCOs), Dental Maintenance Organizations (DMOs).
• Includes pharmacy benefits.
• Eligibility denials for the Medically Dependent Children’s Program waiver and STAR+PLUS Home and Community Based Services waiver based on medical necessity
• Certain Medicaid Waiver populations
Ongoing Work
• Amending HHSC and MCO member notifications to include Fair Hearing and EMR information
• When appropriate, leveraging the editing process to standardize language and increase plain language
• Survey in July 2020 will include PDFs of the notices and provide stakeholders the opportunity to provide input on their clarity
Ongoing Work (continued)
• Development of rules
• Implement MCO contract changes
External Medical Review MCOs/DMOS
15
The EMR process occurs within the Fair Hearing timeline
16
Fair Hearing and EMR Timelines
A “regular” Fair Hearing is a non-emergency Fair Hearing and is completed within standard processing timeframes. The standard processing timeframe for MCO-related Fair Hearing decisions is 90
days from the date the MCO internal appeal is requested, not including the number of days the member takes to request the fair
hearing after the MCO internal appeal is completed.
17
Fair Hearing and EMR Timelines (continued)
An emergency Fair Hearing is a Fair Hearing which meets expedited criteria. Expedited criteria is met when the MCO determines or the
provider indicates taking the time for a standard resolution could seriously jeopardize the enrollee's life, physical or mental health, or ability to attain, maintain, or regain maximum function. Emergency Fair Hearings must be
completed within 3 business days from the date the MCO provides information indicating the expedited criteria is met.
18
EMR Key Takeaways
• The timeframe to request a State Fair Hearing does not change.
• The requirements for continued benefits does not change.
• The requirements for an emergency appeal do not change.
• The Member must exhaust the Internal MCO Appeal prior to requesting a State Fair Hearing and EMR.
19
EMR Key Takeaways (continued)
• The member or MCO or DMO may not submit additional information to the IRO.
• Changes in condition or new information should be submitted to the MCO or DMO.
• If the Member or MCO or DMO requests, the IRO must attend the State Fair Hearing.
20
End User Training Module Specifics
• The EUT process will occur in both phases of the IRO project
• Phase I – Development and Deployment
• Phase II – Refinement and Maintenance
• The training modules will provide a comprehensive overview of the Medicaid programs, benefits and eligibility, supports, resources for the external medical review and independent medical review organization process to external and internal stakeholders as related to the fair hearings and member appeals process.
21
End User Training Module Specifics (continued)
• All identified external and internal stakeholders will complete a mandatory initial training and complete an attestation to submit to HHSC as verification they are ready to conduct business on the operational start date.
• Targeted IRO/EMR Training Module Audiences
• External Audiences:
23
Modules Developed: • EMR Process • Program Overview • Medical Benefits
(amount, duration and scope)
• MCO Fair Hearing/ Appeals
4/1/2020 - 5/14/2020
Module Development
Module Pre Roll-out Process Goal – to obtain user feedback and user experience and aid in module finalization • Modules emailed to
internal stakeholders to complete and submit feedback to the workgroup-
8/1/2020 - 8/15/2020
Key Activities: • Conduct trainings with IRO
Vendors, MCOs, DMOs, TMHP and HHSC staff to ensure they are ready to begin completing EMRs on the operational start date
6/3/2020
Committee Approval Meeting • Identify who will maintain
website • Establish training Completion
First Website Progress Check
IRO/EMR Project Go-Live Date
24
Background
Key Policy, Concepts & Procedures
Client Notification Changes N/A
• Uniformed Managed Care Manual (UMCM) • Uniformed Managed Care Contract (UMCC) • Texas Administrative Code (TACT) • Texas Medicaid Provider Procedures Manual (TMPM) • Managed Care Webpages • Texas Medicaid & Healthcare Partnership TMHP Website
Module Example
26
• Establish Learner Requirements • Identify when does subsequent training need to be
conducted after initial training
• Develop an attestation process for stakeholders to verify completion of training prior to operational start date
• Website Development • Develop a website for the training modules. Both
internal and external stakeholders will have access
• Designate HHSC staff who will be responsible for maintaining the website and updating the training modules to ensure consistency with latest policy, benefits and services.
Key Takeaways
• Each IRO stakeholder shall complete all of the end user training modules prior to the operational start date 9/1/2020.
• Each stakeholder organization will submit attestation documentation to HHSC as verification they have completed the modules and agree to abide by HHSC policy and procedures.
27
Key Takeaways (continued)
• All training modules will be maintained by HHSC and updated as necessary to ensure consistency with managed care policy, legislative and contractual information.
• The training module website will be utilized as a space to create a historical training library for stakeholders to utilize for reference .
28
Senate Bill 1207: Member Notice Requirements
Senate Bill 1207 mandated HHSC to ensure notices sent by HHSC or managed care organizations to a Medicaid recipient or provider regarding the denial, partial denial, reduction, or termination of a service to include:
• Information required by federal and state law and applicable regulations;
• Clear and easy-to-understand explanation of the reason for the decision; and
• An educational component that includes a description of the recipient's rights, an explanation of the process related to appeals and Medicaid fair hearings, and a description of the role of an external medical review
29
• Improve member understanding
• Enhance consistency of notices across MCOs and ensure they are compliant with regulatory requirements
• Incorporate the external medical review process
• Include MCO and HHSC contact information for Members who need assistance
30
Senate Bill 1207 – Revisions to Uniform Managed Care Manual, Chapter 3.21, Medicaid Managed Care Notices of Actions Required
• Notices are for service-level denials only
• PES has a different process for eligibility MN denials
• Two notices
• Notice 1 is sent at time of adverse benefit determination
• Notice 2 is sent after an MCO internal appeal
31
Senate Bill 1207 – Revisions to Uniform Managed Care Manual, Chapter 3.21, Medicaid Managed Care Notices of Actions Required (cont.)
• Each notice includes a letter, flyer, and form
• Letter - Details the adverse benefit determination
• Flyer - Explains appeal, external medical review, and fair hearing process
• Form - Allows the member to request an appeal, external medical review, and/or fair hearing 32
Member Notices: Current Steps & Upcoming
• Obtain stakeholder input on sample mock notices through a survey
• Submit UMCM 3.21 chapter revisions for internal routing – 6/30/2020
• Finalize and submit UMCM 3.21 – 7/15/2020
• Obtain MCO feedback through the UMCM contractual process
• New template effective in UMCM – 9/1/2020
33
• Member gets adverse determination
• Small mention of options after internal appeal
• Continuation of benefits
• Internal Appeal occurs between adverse determination and internal appeal decision
• Member Notice Content
• Continuation of benefits
• FH & EMR form
• Member gets EMR decision • If an External Medical Review is required it
occurs between internal appeal decision and EMR decision
• Member Notice Content • IRO Sends
• EMR evaluation outcome (sent to client, MCO & HHSC)
• Details on next steps for FH • Option to withdraw FH request, if any
• Member gets FH decision • If an External Medical Review is required a
Fair Hearing occurs between EMR decision and FH decision.
• If an External Medical Review is not required a Fair Hearing occurs between internal appeal decision and FH decision.
• Member Notice Content • HHSC Sends
• Standard existing fair hearing decisions
Appendix B - External Medical Review MDCP and STAR Plus HCBS - Text Explanation
• Individual gets adverse determination
• Provides an opportunity for the Member to provide additional information
• Individual gets final decision
• Member Notice Content
• Continuation of benefits
• FH & EMR form
• Individual gets EMR decision • If an External Medical Review is required it
occurs between internal appeal decision and EMR decision
• Member Notice Content • IRO/HHSC Sends
• EMR evaluation outcome (sent to HHSC)
• HHSC send Member outcome notice • Details on next steps for FH • Option to withdraw FH request, if
any
• Individual gets FH decision • If an External Medical Review is required a
Fair Hearing occurs between EMR decision and FH decision.
• If an External Medical Review is not required a Fair Hearing occurs between final decision and FH decision.
• Member Notice Content • HHSC Sends
• Standard existing fair hearing decisions
Appendix C - End User Training Key Milestones
• 04/01/2020 – 05/14/2020: Module Development • EMR Process, Program Overview, Medical Benefits (amount, duration and scope),
MCO Fair Hearing/Appeals
• 05/14/2020 – 06/03/2020: Module Pre-Rollout Period • Goal - to obtain user feedback and user experience and aid in module finalization.
Modules emailed to internal stakeholders to complete and submit feedback to the workgroup.
• 06/02/2020 – 07/31/2020: Website Development • Key Activities: HHSC Portal Steering Committee Approval Meeting, Identify who will
maintain website, Establish training Completion Attestation Process • 06/23/2020: First Website Progress Check • 07/05/2020: Training Module Schedule Notice • 07/14/2020: Second Website Progress Check • 07/28/2020: Training Module Website Preview
• 08/01/2020 – 08/15/2020: Initial Module Training Period • Key Activities: Conduct trainings with IRO Vendors, MCOs, DMOs, TMHP and HHSC
staff to ensure they are ready to begin completing EMRs on the operational start date
• 09/01/2020: IRO/EMR Project Go-Live Date
Structure Bookmarks
SMMCAC Complaints,
