executed amendment agreement between nys attorney general and excellus
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7/25/2019 Executed Amendment agreement between NYS Attorney General and Excellus
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AMENDMENT TO ASSURANCE OF DISCONTINUANCE NO. 14-201
Assurance of Discontinuance between the New York State Office of the Attorney
General ( OAG ) and Excellus Health Plan, Inc. ( Excellus ), No. 14-201 (the Assurance ),
dated March 13, 2015, is amended as follows:
1. Auto-Approval for Substance Use Disorder ( SUD ) Treatment
Excellus will auto-approve higher levels of treatment for opioid addiction as follows: 5
days for inpatient SUD detoxification; 14 days for inpatient SUD rehabilitation; and 14 days for
SUD residential treatment. The auto-approval will apply to all New York-licensed facilities. The
new approval process will begin on June 27, 2016. The auto-approval process will be as follows:
a.
Facility contacts Excellus at the time of admission;
b.
Excellus medical intake staff collect information to confirm member enrollment and
eligibility for benefits;
c. Excellus medical intake will confirm that the primary diagnosis is moderate or severe
opioid use disorder (Excellus will accept the providers' conclusion as to diagnosis);
d. Excellus intake staff collect relevant clinical information from the facility (which does
not affect the auto-approval process but is collected for purposes of conducting care
management and clinical review for requests for additional days);
e.
Excellus intake staff transmit clinical information to utilization management staff;
f. Excellus utilization management staff communicates an approval to the facility the
same day if authorization is requested by 2 p.m., and otherwise within 24 hours; and
g.
If the facility requests authorization for additional days beyond the auto-approved
periods noted above, Excellus may conduct a clinical review to determine whether
those additional days will be approved.
Periods of treatment auto-approved by Excellus as set forth above will not be subject to
medical necessity review, including retrospective review.
Excellus will provide notice to providers and members regarding the auto-approval
process, in a form agreed to by the OAG. Excellus will maintain the auto-approval process for at
least one year after the date of execution of this Amendment. If Excellus seeks to modify the
process in any manner after that time, it will provide written notice to the OAG and the parties
will meet and confer regarding the proposed modifications.
Auto-a pprov al for inpatient detoxification, inpatient rehabilitation and residential services will apply to
the extent such services re covered under the mem ber's subscriber contract benefit package.
Substantially all members' benefit packages cover these services.
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To the extent that New York law is more favorable to members and/or providers than
Excellus's auto-approval process, the requirements of applicable New York law will control and
govern.
2.
Switch to LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) Criteria
Excellus will discontinue its use of InterQual medical necessity criteria for review of
SUD services and use the most recent version of LOCADTR issued by the New York State
Office of Alcoholism and Substance Abuse Services for such reviews. The transition to
LOCADTR 3.0 (the current version) will apply to Excellus's commercial and Medicaid Managed
Care lines of business. It will be implemented for Medicaid Managed Care on July 1,2016, and
for commercial by September 1,2016.
3.
Improvements to Excellus's Review Procedures
In conducting reviews for SUD detoxification, SUD inpatient rehabilitation, and SUD
residential treatment following the full transition to LOCADTR (i.e., September 1,2016),
Excellus will implement the following procedures:
a.
Excellus's reviewers will use a questionnaire that asks providers for information
about the m emb er corresponding to: (i) each elem ent of the criteria used by Exc ellus
(for examp le, if the criteria contain a list of factors that m ay satisfy the criterion, the
reviewer m ust ask about each factor); and (ii) each item listed in Assurance Exhibit
A. Excellus's reviewers will document the questions and answers in the member's
case file.
b.
Excellus's reviewers will ask providers how they made their assessment as to the
proper level of care for the member and the criteria they used to make such
assessment. Excellus's reviewers will document the questions and answers in the
member's case file.
c.
Excellus's reviewers will ask providers about, and will consult Excellus's files and all
reasonably accessible medical records for relevant information about the member's
treatment history, as necessary, and will docum ent such efforts, and the information
obtained, in the member's case file.
d.
Subject to receipt of any required HIPAA authorizations, Excellus's reviewers will
attempt to obtain additional information from pro viders, parents and other family
members, as needed, and will document such efforts, and the information obtained, in
the member's case file.
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e. In its quarterly Compliance Administrator Reports issued pursuant to Paragraph 59 of
the Assurance, Excellus will provide written proof to the OAG that it has complied
with these provisions in each review it conducts.
4. Improvements to Excellus's Adverse Determination Letters
Before Excellus issues adverse determ ination letters for inpatient SUD detoxification,
inpatient SUD rehab ilitation, and SUD residential treatmen t, an Excellus Medical Director w ill
review the clinical rationale portion o f the letter for accuracy.
Excellus will continue to implement the following measures set forth in its Plan of
Corrective Action, dated April 8, 2016:
a. Conducting training sessions with discussion and critiques of rationale drafting and
explanation of the Compliance audit process.
b. Retaining an Accreditation Compliance & Quality Administrator specific for
Utilization Management with focused attention on the AOD, with behavioral health
clinical experience.
c. Reviewing monthly audits directly from the Compliance Department with the UM
Supervisor, including direct 1: 1 clinical UM staff review and acknowledgement of
audit results specific to their cases, focused pre-review of individual staff mem bers'
denial letters, review for com pliance and edited, as appropriate, and periodic sharing
with the Corporate Compliance representative for input and collaboration.
d. Conducting UM staff team meetings dedicated to AOD training and compliance in the
following areas:
I) Letter denial content and verbiage.
2)
Review of medical necessity criteria for behavioral health and consistent
application.
3)
Specific deficient audit results with training on the p articular item of deficiency.
4)
Work flow review/ remind ers for consistent application.
e. Multi-disciplinary team meetings including UM staff, operational staff and Medical
Directors to discuss m edical necessity criteria for behavioral health, and its application
to case reviews.
f. Identification, through audit, clinicians who need additional assistance/training in letter
writing, with those team memb ers on 100 up front review of their letters until
sustained improvement is demonstrated.
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g.
Convening Medical Director Team M eetings dedicated to AOD training and
compliance, including the BH Medical Directors including the BH Chief Medical
Officer Corporate Compliance Manager BH UM Supervisor and the UM
Compliance Administrator, to review consistent application of medical necessity
criteria and workflow review.
h.
Assigning one Behavioral Health M edical Director (with BH MD backup) to focus
exclusively on SUD reviews and attain greater compliance and consistency. Other
team members will be included for coverage and training purposes.
i.
The Compliance Administrator and her designees will oversee the activities described
in the plan of correction and report on progress in the quarterly Compliance
Administrator reports.
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AGREED TO BY THE PARTIES:
Dated: Rochester, New York
xcellus Health Plan, Inc.
01 46 0,0
,2016
y:
Stephen Sloan
Executive VP, Chief Adm in. Off., & General
Counsel
Dated: New York, New York
RIC T. SCHNEIDERIVIAN
Attorney General of the State of New York
,2016
LISA LANDAU
Health Care Bureau Chief
By:
MICHAEL D. REISMAN
Assistant Attorney General
Health Care Bureau
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