We may issue denials/adverse determinations. We issue these when:
The service, item, or drug is not medically necessary.
The service, item, or drug is not covered.
We receive no supporting (or incomplete) information.
If you disagree with our determination, you may appeal on behalf of the member. Appeal information is on the determination letter we send you. Our medical reviewers are able to discuss the denial with the treating or attending health care provider.
We make our authorization determination and communicate it based on the nature of the member’s medical condition and following state and federal law.
We base our decisions on sound clinical evidence. This includes:
Medical records review.
Consultation with the treating health care providers.
Review of nationally recognized criteria; for example, Medicare Coverage Criteria.
Denials, delays or modifications
Requests that do not meet the criteria for immediate authorization are reviewed by the Medical Director or the Utilization Management Committee (UMC), designated health care provider, or presented to the collective UMC or subcommittee.
Only a health care provider (MD or DO, psychiatrist, doctoral level clinical psychologist or certified addiction medicine specialist, as appropriate) may delay, modify or deny services to a member for reasons of medical necessity. We use board-certified licensed health care providers from appropriate specialty areas to help determine medical necessity.
Health care providers will not review their own referral requests.
Our qualified staff members review referral requests being considered for denial.
Any referral request where the medical necessity or the proposed treatment plan is not clear can be clarified by discussion with the health care provider thereafter. Complex cases go to the UMC/Medical Director for further discussion and decision.
Individual(s) who meet the qualifications of holding financial ownership interest in the organization may not influence the clinical decision making regarding payment or denial of a service.
Prior authorization determinations may include the following decision:
Approved as requested — No changes.
Approved as modified — Referral approved, but the requested health care provider or treatment plan is modified. Denial letter must be sent if requested health care provider is changed or specific treatment modality is changed (e.g., requested chiropractic, approved physical therapy).
Extension — Delay of decision regarding a specific service (e.g., need additional documentation, information, or require consultation by an expert reviewer).
CMS allows delays of decision (extensions) for MA members when the extension is justified and in the member’s interest:
Due to the need for medical evidence from a non-contracted health care provider that may change the decision to deny an item or service.
Due to extraordinary, exigent, or other non-routine circumstances and is in the member’s interest.
Delay in Delivery — Access to an approved service postponed for a specified period or until a specified date will occur. This is not the same as a modification. A written notification in the denial letter format is required.
Denied — Non-authorization of a request for health care services. Reasons for denials of requests for services include, but are not limited to, the following:
Not a covered benefit — the requested service(s) is a direct exclusion of benefits under the member’s benefit plan — you must note a specific benefit exclusion.
Not medically necessary or benefit coverage limitation — specify criteria or guidelines used in making the determination as it relates to the member’s health condition.
Member not eligible at the time of service.
Benefit exhausted — include specific information as to what benefit was exhausted and when.
Not a network provider — a network provider/service is available.
Experimental, investigational or unproven procedure/treatment.