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MP CareSolutions (MPCS)

2017 Policies & Procedures

For Management of

Medicaid Managed Care (MMC), Child Health Plus

(CHP), Health & Recovery Plan (HARP), Essential Plan

(EP) Contracts

Utilization Management

&

Appeals & Grievances (Advocacy)

1

2017 MPCS Policies & Procedures MMC, CHP, HARP, and EP Contracts



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

31

MPCS 06- UM Behavioral Health

32

MPCS 08- Appeals, Grievances, Fair Hearing

34

MPCS 09- UM Inter-Rater Reliability

46

MPCS 10- Collection & Documentation of Relevant Information for UR

Determinations

48

MPCS 11-Utilization Management Personnel

52

MPCS 12-Confidentiality

59

MPCS 13- Technology Evaluation & Medical Policy for UR Determinations

62

MPCS 14- Continuity of Care

64

MPCS 15- Emergency Services

66

MPCS 16- UM Out of Network Requests

67

MPCS 19- UM Quality Improvement Initiatives

71

MPCS 20- UM Clinical Peer Reviewers

75

MPCS 21- UM Pharmacy Management

77

MPCS 22- LTSS

81

2




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

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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.

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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 state 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.

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MPCS 01

Utilization Management (UM) & Advocacy [Appeals & Grievances

(Complaints)] Programs

Structure & Review

Policy Statement

MPCS’ Utilization Management (UM) & Advocacy [Appeals & Grievances (complaints) ]

programs are reviewed at least on an annual basis by the MPCS’ UM & Advocacy

Committee. The committee is responsible for advising upon all UM & Advocacy quality

activities as applicable to the services that MPCS is delegated to manage by its client

health plans, and monitoring that said activities are in fulfillment of quality and

compliance requirements set forth by state, federal, & accreditation bodies to ensure the

highest quality of 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 that is is focused on recovery, resiliency, and

rehabilitation, pharmacy care, and community and facility based long term support services

and continuity and coordination of such care across all service settings, including

transitional care.

The committee is primarily comprised of practicing physicians, specialists, and MPCS’

clinical management staff. Members are appointed by the chair 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 & Advocacy programs and its components

and chairs the committee. The CMO holds primary accountability for oversight of the UM

& Advocacy programs and its entirety. 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. In instances where contractors, agents,

or vendors conduct utilization review on behalf of MPCS, it is expected that said entity 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 their utilization review program and processes. However, said

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.

The MPCS committee meets at least on a quarterly basis. Meetings are structured by an

agenda. Meeting minutes provide support of committee activities. Committee activity is

also reported to MPCS’ client health plans in accordance to the functions that MPCS is

delegated to manage for the health plan. A summary of committee activities are provided

in the section below. 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.

6




Procedure

During the first quarter of the calendar year, MPCS program descriptions, policies,

and procedures affiliated with the UM and Advocacy services that MPCS is

delegated to manage by its client health plans are reviewed for necessary updates

to the program structure, clinical review criteria and procedures, responsibilities,

and annual goals & objectives. Updates are then submitted to the committee for

review, feedback, and approval no later than the second quarter of the calendar year,

and changes are then reported to MPCS’ client health plans within this time frame,

or at a frequency determined by the client health plan. However, program policies

are also continuously updated as needed, and such revisions are presented for

committee review and approval as the need arises. MPCS’ client health plans are

notified of these changes at a frequency determined by the client health plan.

The performance dashboard is a living document that serves as a tool for reporting

upon overall quality, compliance, and performance of the UM & Advocacy services

that MPCS is delegated to manage by their client health plans. These measures are

reported to the MPCS committee, and to MPCS’ client health plans in accordance

to the services that are delegated to MPCS to manage, and at a frequency

determined by the client health plan. All such measures are designed to ensure that

program activities are functioning at a level that help maintain, restore, or improve

health outcomes of individuals and populations. A summary of the quality,

compliance, and performance measures are provided below:

UM & Advocacy [Appeals,

Grievance (Complaints) ]

Volumes

& Timeliness Standards

Such measures track and ensure that time frames set forth

by state, federal, & accreditation bodies. 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 & Advocacy volumes are essential to

ensuring adequate staffing is available to manage all

service requests received in the department within required

time frames. Monthly time frame percentages are calculated

and reported upon to the committee and 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.

Both volume and timeliness metrics are reported to the

committee, and to the client health plan at a manner and

frequency dictated by the client health plan.

Case Management & Care

Coordination (CM)

Referral Volume

This measure tracks that members who meet specific triggers

are referred to case management for care coordination,

support, education, and resources relating to the condition(s)

in which members are receiving treatment for. To calculate

7




the percentage of cases appropriately referred to the CM

department, the volume of cases that are appropriately

referred is divided by the total number of referred cases.

Trend Analysis Trend analysis is utilized to evaluate effectiveness of the

UR and Advocacy programs, and to identify areas of

improvement. 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 committee for

review.

Trends analyzed include, but are not limited to type of

reviews denied and approved through the UR & Advocacy

programs and over and under- utilization of services.

Member & Provider

Satisfaction Surveys as it

relates to the UR process

Member and provider satisfaction surveys are conducted on

an annual basis to determine overall satisfaction with the

utilization review process.

MPCS uses data collected from the biannual New York

State Department of Health sponsored Consumer

Assessment of Healthcare Providers and Systems

(CAHPS) survey to measure member satisfaction from a

sampling of enrollees, as 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, all of 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 departmental staff, and

designated staff are appointed to design, implement, and

8




monitor interventions for areas where corrective action is

required. Results and interventions are then reported to the

UM 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 across all review types and lines of businesses

managed by MPCS. 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 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 & Advocacy Chart

Audits

Chart auditing is essential to ensuring compliance to

state, federal, accreditation, and internal policies and

procedures on chart documentation

standards, letter requirements, review criteria, and

review priority. Two charts are

randomly selected from a pooling of all review types and

lines of businesses managed by MPCS 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 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

9




than 90% accuracy per chart reviewed, with an average

of 90% per month. A score less than 90% requires

remediation on the identified errors by Quality Specialist

and/or supervisor. A random chart completed on a date that

follows remediation to ensure reconciliation of the

identified error. If the same error is identified during

subsequent audits, disciplinary measures may be initiated.

A score of 95% or better is deemed as exceeding

expectations. Monthly chart audit scores are aggregated for

yearly total to include on performance reviews. See policy

titled UM & Advocacy Chart Audit Program for additional

details.

Member and Provider

Complaints (Grievances)

Complaints are investigated as they arise. MPCS uses the

definition of a complaint (or grievance) as outlined in New

York State Public Health Law 42 CFR 438.488 as a

guideline for what constitutes a compliant. 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 as fast as the enrollee’s

condition requires, but no later than then NYS timeliness

standards for complaint resolution, and addressed by the

most appropriately qualified staff person based on the

nature of the complaint. Complaints are 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 the committee for

review and feedback.

Complaints are reported to the client health at a frequency

dictated by the client health plan by review and service

type, volume, outcome, and timeliness of resolution. In

instances where MPCS is delegated to manage the formal

complaint process by the client health plan, MPCS partners

with the client health plan to report complaint metrics to the

New York State Department of Health (NYSDOH) through

the Health Commerce System (HCS) portal at the

frequency and in the format as required by the NYSDOH.

Program Goals &

Objectives

Yearly program goals and objectives are set forth each year

in efforts to maintain and/or improve upon program

performance. Progress towards meeting goals and

objectives are reported to the committee for feedback.

Performance Appraisals

The performance of all staff members are 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.

10




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


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

11




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)

12




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 member (or designee) or provider(s) may also request an

extension verbally or in writing. 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 member

(or designee) or provider(s) may also request an extension verbally or in

writing. 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 information has already been received.

13




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


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

member (or designee) or provider(s) may also request an extension verbally

or in writing. The request must specify the time period given to 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 member

(or designee) or provider(s) may also request an extension verbally or in

writing .The request must specify the time period given to 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 information has already been received.

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

member (or designee) or provider(s) may also request an extension verbally

or in writing. 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

14




Table 2

Medicaid Managed Care & HARP

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 verbally or in

writing. 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. Sufficient documentation of the extension determination

must be maintained in order to demonstrate, upon NYSDOH request, that the extension

was justified. 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)


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 the provider(s) may also request an extension

verbally or in writing. 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










and in writing as fast as the member’s condition requires and within 1 business day after


15




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 verbally or in writing. 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 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










and in writing as fast as the member’s condition requires and within 1 business day after


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

verbally or in writing. 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 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. Sufficient documentation of the

extension determination must be maintained in order to demonstrate, upon NYSDOH

request, that the extension was justified. 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.

16




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. Retrospective reviews are

inclusive of all claim type and post-service

reivews.

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


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


17




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


18




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

19




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:


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



20




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


21




**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.

All written notices are in easily understood language and are accessible to non-English

speaking and visually impaired members. Members also have the right to receive

information about MPCS and managed care in a manner which does not disclose the

members as participating in these government programs, provided that inclusion of MPCS’

name is not considered a violation of this provision, and be treated with respect and due

consideration for his or her dignity and privacy. Neither MPCS or its participating

providers contractors will adversely regard a member who exercises these rights.

All extension notices must include the following. Please note that notices to providers are

the same a notice to the members.

Reason for extension and 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.

A statement that the notice is available in other languages and format for special

needs, including oral interpretation of the notice, and information on how to access

these services.

In addition, sufficient documentation of the extension determination must be maintained

in order to demonstrate, upon NYSDOH request, that the extension was justified.

All written adverse determination (or action) notices must at minimum include the

following. Notice of action to providers must contain the same information as notice of

action to the members.

Total of denied services and from & to dates of such and description of the action to

be taken.

The rationale for the denial must be provided for both clinical and non-clinical

denials, as well as a reference to the criteria on which the denial was based, and the

medical service, treatment or procedure in question. The rational for denial, clinical

or otherwise, must be specific in order to enable the enrollee or health care

22




provider to make an informed judgment regarding whether or not to appeal the

adverse determination, and the grounds for such an appeal. In addition to the

aforementioned, if the denial is clinical in nature, a reference to the enrollee and the

nature of his/her medical condition must be provided, and whether the treatment or

procedure is /was not medically necessary or experimental/investigation as

applicable.

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 for filing an oral and/or written action appeal) pursuant to New York State

Public Health Law and or New York State Insurance Department, 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, and a description of what additional

information, if any, must be obtained from any source in order to make an appeal

determination.

A 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), and that MPCS will not retaliate or take any discriminatory

action against the member if an appeal or grievance is filed.

The right of the enrollee to designate a representative to file an appeal or grievance

on the enrollee’s behalf.

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.

For MMC, FHP, and HARP members, a notice entitled “Managed Care Action

Taken” for denial of benefits or for termination or reduction in benefits, as

applicable, containing the enrollee’s Fair Hearing and Aid Continuing rights.

A statement that the notice is available in other languages and format for special

needs, including oral interpretation of the notice, and information on how to access

these services.

Any additional information required to render a decision on appeal or grievance.

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 provider 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

23




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 an external appeal application.

24




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.

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

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

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

25




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



mailto:[email protected]

26




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 annually (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

for all products and populations that MPCS partners with their client health plans to

manage, which includes Medicaid Managed Care (MMC), Health & Recovery Program

(HARP), Child Health Plus (CHP), Essential Plan (EP), Medically Fragile children, and

children receiving (Home & Community Based Services (HCBS).

Criteria is applied in a hierarchy fashion that begins with New York State (NYS) Medicaid

criteria. MPCS follows least restrictive criteria if NYS Medicaid criteria is not available for

the service requested. See hierarchy below.

I. New York State Medicaid Criteria 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. NYS Medicaid Medical Necessity Standards,

Coverage Criteria & Guidelines. Sources include, but are not

limited to:

eMedNY

Medicaid Managed Care Contract

NYS Monthly Medicaid Updates

Other related standards that are or may be developed by

NYS Department of Health (DOH), NYS Office of Children

& Family Services (OCFS), NYS Office of Alcoholism &

Substance Abuse Services(OASAS), NYS office of Mental

Health(OMH), NYS Office for People with Developmental

Disabilities (OPWDD)

NYS LOCADTR 3.0 for SUD services

27




II. If NYS Medicaid criteria is unavailable for the service

requested, the least restrictive of the below criteria set is

followed:

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 for

determining clinical necessity.

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 or P.O. Box 240,

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.

28




MPCS 04

Utilization Review Process

Policy Statement

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

clinical necessity determinations on medical (which includes pharmacy and radiology) and

behavioral health care services for which MP CareSolutions determines is subject to the

utilization review process. Service requests may be inpatient or outpatient, prospective,

concurrent, retrospective, urgent or non-urgent, inclusive of the review types outlined in

Table 1 of this policy, and are reviewed by appropriately qualified UM staff with current,

valid, and unrestricted licenses. Refer to policy titled MPCS 11-UtilizationManagement

Personnel for full job descriptions and reviewer accountabilities. Additionally, MPCS will

participate in the State’s efforts to promote the delivery of services in a culturally

competent manner to all members, including those with limited English proficiency, and

diverse cultural and ethnic backgrounds

If MPCS subcontracts with for service authorization determinations and utilization review,

MPCS ensures that its subcontractors have in place and follow written policies and

procedures for delegated activities regarding collection and processing of requests for initial

and continuing authorization of services consistent with SSL § 364-j (25), Article 49 of the

PHL, 10 NYCRR Part 98, 42 CFR Part 438, Appendix F of the Medicaid Managed Care

contract, and MPCS policies and procedures.

Table 1 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.

Hospice Services MPCS does not require prior authorization for Hospice

services. Should prior authorization for Hospice services

be required, MPCS would review and make

determination on Hospice services in accordance with

Appendix F of the Medicaid Managed Care contract.

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.

In addition, MPCS will make all reasonable efforts to

work with, hospitals, Article 31 mental health facilities,

Article 32 OASAS programs, RHCFs and outpatient and

community-based providers in developing discharge

plans for members when a change in the member’s level

of care is proposed. As part of discharge planning,

MPCS shall arrange for and authorize covered services

as medically necessary for the member’s care. If the

member is in need of Long Term Services and

Supports(LTSS), the discharge plan will be prepared in

accordance with Appendix S of the Medicaid Managed

29




Care contract. For the purposes of this section,

“reasonable efforts” include, but are not limited to, as

applicable and appropriate to the member’s

circumstances ( participation in discharge planning

meetings, face to face meetings with the member to

assess needs and preferences for care, identification of

medical, environmental or social obstacles to safe

discharge; referral to the member’s care management

program, assignment to a Health Home and

collaboration with its outreach, enrollment and care

management efforts, referral to Medicaid waiver

programs; and/or referral to state and local government

agencies).

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

30




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.

Particularly, members may request referral for mental

health services, chemical dependency services, vision

services, Diagnosis and Treatment of Tuberculosis,

Family Planning and Reproductive Health Services, and

Article 28 Clinics Operated by Academic Dental

Centers, and any service where in the absence of the

required medical attention, would result in placing one’s

medical or behavioral health in in serious jeopardy,

serious impairment of bodily functions, serious

dysfunction of any bodily organ, or serious

disfigurement. Please note that emergency services do

not require referral or prior authorization.

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.

31




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

32




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.

a. 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 routing to appropriate decision maker for additional review if

applicable), and criteria for which the decision was based upon.

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

routed to the appropriate decision maker for review:

Adverse medical necessity determinations must be made by 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, with no previous involvement in the

member’s health care, and must possess the same or similar specialty as the

provider requesting the service. The same principles apply for adverse

determinations for services and durable medical equipment for Medically

Fragile Children living at home, and the physician reviewer must also include

consideration for the family in their decision making process.

Adverse determinations that are experimental/investigational in nature must be

made by 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, with no previous

involvement in the member’s health care, and must possess the same or similar

specialty as the provider requesting the service. An experimental/investigational

33




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.

Adverse determinations that involve out-of-network services must be made by

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, with no previous involvement in

the member’s health care, and must possess the same or similar specialty as the

provider requesting the service. Please see policy titled MPCS 16- Out of

Network Requests for detailed instructions on the process.

Adverse determinations, other than those regarding medical necessity,

experimental/investigational services, or out-of-network services must be made

by a licensed, certified or registered health professional when such

determination is based on an assessment of the enrollee’s health status or of the

appropriateness of the level, quantity, or delivery method of care. This

requirement applies to service authorization requests that include, but are not

limited to those services included in the benefit package, referrals, and out-of-

network services.

4. The decision makers, physicians and licensed, certified, or registered health professional

alike, document his/her determination in the designated software system using standard

UM documentation guidelines. All cases include the decision date, name of decision

maker, 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 of member and provider verbal and written

notices, if the utilization reviewer is not the decision maker. 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

34




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-

35




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

No contract or agreement between MPCS and a health care provider shall contain any

clause purporting to transfer to the health care provider by indemnification or otherwise any

liability relating to activities, actions or omissions of MPCS as opposed to the health care

provider.

Enrollee Rights Members have the right to receive information on available treatment options and

alternative presented in a manner appropriate to the member’s condition and ability to

understand, participate in decisions regarding his or her health care, including the right to

refuse treatment, be free from any form of restraint or seclusion used as a means of

coercion, discipline, convenience or retaliation, as specified in Federal regulations on the

use of restraints and seclusion, and if the privacy rule, as set forth in 45 CFR Parts 160 and

164, Subparts A and E applies, request and receive a copy of his or her medical records and

request that they be amended or corrected, as specified in 45 CFR §§ 164.524 and 164.526.

Neither MPCS or its participating providers will adversely regard a member who exercises

these rights.

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.

36




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. Communications received after normal business hours are returned on the next business day and communications received after midnight on Monday–Friday are responded to on the same business day. Local and toll free telephone numbers are readily displayed on the member’s ID card, are published on the client health plan’s website, and are also provided in written UM determination notices. UM personnel are also available during business hours 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.

37




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. Communications received after normal business hours are returned on the next business day, and communications received after midnight on Monday–Friday are responded to on the same business day. 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



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.

MPCS permits members (or designees) to generate referrals for mental health and chemical

dependency services without requiring preauthorization or referral from their PCP. For the

MMC Program, in the case of children, such self-referrals may originate at the request of a

school guidance counselor (with parental or guardian consent, or pursuant to procedures set

forth in Section 33.21 of the Mental Hygiene Law), LDSS Official, Judicial Official,

Probation Officer, parent or similar source. Receipt of Screening, Brief Intervention, and


38




Referral to Treatment (SBIRT) for Chemical Dependency does not preclude the member

from self-referring for subsequent chemical dependency services.

MPCS makes a listing of participating mental health and Chemical Dependence Services

providers available to its members, which specifies those providers that specialize in

children’s mental health services. MPCS ensures that participating providers have and use

formal assessment instruments to identify a member’s mental health and chemical

dependency needs. MPCS ensures that members receive follow up from appropriate

providers based on findings of their mental health and/or chemical dependency

assessments, consistent with Section 15.2(a)(x) and (xi) of the Medicaid Managed Care

contract.

MPCS allows any HIV SNP participating PCP, with appropriate enrollee consent, to

request that a representative of the HIV SNP or behavioral health provider contact any HIV

SNP member they believe to be in need of mental health or chemical dependency

Services, and attempt to arrange for an evaluation of their needs.

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

assessment occurs directly at the treatment source.

Tracking Mechanism


entirety.

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.

39




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 P.O. Box 240,

Pittsford, N.Y. 14534; by telephone at 1-800-683-3781 (for TTY/TDD services, call 1-

877-200-2326)]; by fax at 1-888-273-8296; in person (or mail) at 1120 Pittsford-Victor

Road, Pittsford, N.Y. 14534, and by email at [email protected].

If received orally, an Advocacy Associate will document a summary of the appeal in

writing for the member to review, modify if needed, sign, and return to MPCS for filing.

The oral confirmation can be sent with the acknowledgement letter or separately. If the

member or provider requests expedited resolution of the appeal, the oral appeal does not


40




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.

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), Child Health Plus (CHP), and Health & Recovery

Plan (HARP) 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 with Essential Plan (commercial) insurance have up to one hundred eighty

(180) calendar days. MMC & HARP 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. A legal estate representative of a

deceased members may also serve as a designee.

MPCS and its entities 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. The file also contains a mailed and dated copy

of acknowledgement letter, the appeal determination that references the benefit

provision, guideline, protocol, or other similar criterion on which the appeal decision is

based, 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, qualifications, specialties, and credentials of the

personnel participating in the appeal review.

Members 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,

41




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 appeal 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.

Standard appeals for MMC, CHP, and HARP members are decided within thirty

(30) calendar days from receipt of the appeal, or as fast as the member’s

condition requires. For members with MMC & HARP contracts, 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 with Essential Plan (commercial) insurance, if the appeal relates

to a pre-service matter, a decision is made within thirty (30) calendar days, or as

fast as the member’s condition requires, 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

42




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, or as fast as the member’s condition

requires, 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. 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 HARP members, expedited appeal decisions and verbal

notifications of such decisions must be made as fast as the member’s condition

requires, 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

43




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. For members with

MMC & HARP contracts, 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 HARP members receiving a denial of inpatient substance use treatment prior

to 24 hours of discharge, the admissions will continue to be authorized if the

member (or their designee) requests both an external and internal appeal within

24 hours of receipt of the initial adverse determination. The admissions will be

authorized until there is a decision made on both appeals. Internal appeals are

determined no later than 24 hours of the request (or as fast as the member’s

condition requires) and external appeals are determined no later than 72 hours of

the request (or as fast as the member’s condition requires.

For members with Essential Plan (commercial) insurance, expedited appeals

decisions involving pre-service events will be made as fast as the member’s

condition requires, but no later than 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 an expedited determination within the applicable time

periods per member contract type as noted above 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 Notices of Standard & Expedited Appeals

All decisions generated during the standard and expedited appeals

process must be followed by written notices. Notice of action to

providers must contain the same information as notice of action to the

members.Written notices generated during the appeals process, which

44




include determination notices, final adverse determination notices, and

extension must be dated and include the following:

Language must be easily understood, 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


Notices are also required to contain specific language depending on

the type of notice generated, which is outlined within the sections

below.

In additional to the italicized notice requirements in the beginning of

this section, written determinations and final adverse determination

notices for standard and expedited appeals must also include the

following. Note that notices of final adverse determinations for both

standard and expedited cases shall comply with all requirements of

Article 49 of the Public Health law and will all applicable federal

laws and rules.

The member and the nature of his/her medical

condition and the medical service, treatment or

procedure in question.

The reasons for the determination; provided, however,

that where the determination is adverse, the notice

shall include the clinical rationale for such

determination as applicable to the member..

A reference to the benefit provision, guideline,

protocol, or other similar criterion on which the appeal

decision is based.

For adverse decisions, a clear statement that the notice

constitutes a final adverse determination of either a

medical necessity or experimental or investigational

denial, which shall demonstrate that MPCS considered

enrollee-specific clinical information in its

determination.

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.

A contact person from MPCS and his/her telephone

number, the title, credentials, and qualifications

(including specialties) of individual(s) involved with

the appeal review, the name, full address, and

telephone number of the Plan’s utilization review

agent (if MPCS delegates appeals to an entity other

than MPCS), a contact person from the Plan’s

45




utilization review agent and his/her telephone

number(if MPCS delegates appeals to an entity other

than MPCS, and the member’s coverage type.

For adverse decisions, 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 external 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.

For adverse decisions regarding restrictions on MMC

members under MPCS ’s Restricted Recipient

Program (RRP), the notice must also 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.

For adverse decisions regarding Personal Care

Services for MMC members, the notice must also

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.

46




For adverse decisions regarding prescription

medications denials specified in section10.32 (g) of

the Medicaid Managed Care Model Contract, the

notice must also 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.


this section, notices to the member regarding a Plan-initiated

extension must include 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.

Sufficient documentation of the extension determination must be

maintained in order to demonstrate, upon NYSDOH request, that the

extension was justified.

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

47




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

48




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.

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.

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

49




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.

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 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.

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. Additionally, a member that is covered under the Medicare or

Medicaid program may appeal the denial of a health care service provided,

however, that any determination rendered concerning such denial pursuant to

existing federal and state law relating to the Medicare or Medicaid program or

pursuant to federal law enacted subsequent to the effective date of this title and

providing for all external appeal process for such denials shall be binding on the

member and MPCS and shall supersede any determinations rendered pursuant to

NYS Public Health Law.

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

50




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. 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. Examples of grievances 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. These are classified as intangible grievance (or

complaints), or non-benefit related grievances.

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, a

claim denial, or that an out-of-network authorization was unnecessary. These are

classified as benefit related grievances.

A grievance may be filed by contacting MPCS by mail at P.O. Box 240, Pittsford,

N.Y. 14534; by telephone at 1-800-683-3781 (for TTY/TDD services, call 1-877-

200-2326)]; by fax at 1-888-273-8296; in person (or mail) at 1120 Pittsford-Victor

Road, Pittsford, N.Y. 14534, and by email at [email protected].

If received orally, an Advocacy Associate will document a summary of the

grievance in writing for the member to review, modify if needed, sign, and return to

MPCS for filing. The oral confirmation can be sent with the acknowledgement letter

or separately. If the member or provider requests expedited resolution of the

grievance, the oral grievance does not need to be confirmed in writing. The date of

the oral filing of the grievance will be the date of the grievance for the purposes of

the timeframes for resolution of the grievance. 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, CHP, and HARP 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 with Essential Plan (commercial) insurance


51




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. MPCS must provide members with reasonable assistance with

completing forms and other procedural steps for filing a grievance, including

interpretive and/or TTY/TDD services.

Members must be provided with a reasonable opportunity to present evidence

regarding the grievance, 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 grievance. MPCS must permit the member or a designee, both

before and during the grievance process, an opportunity to examine the member’s

case file, including medical records and any other documents and records

considered during the grievance process. Members also have the right to designate a

representative (including an attorney) to assist him/her in the grievance process. A

legal estate representative of a deceased members may also serve as a designee.

MPCS and its entities keeps all requests and discussions related to a grievance

confidential and will not take any action to penalize or discourage a member or

provider from grieving, seeking dispute resolution, or judicial review of an adverse

determination. 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.

MPCS ensures that must ensure that personnel making grievance determinations

were not involved in previous levels of review or decision-making. For non-clinical

level one grievances, cases are reviewed by personnel who are not subordinate to

the personnel who were involved in the initial determination. Additionally, 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 initial level

one grievance determination. Cases that are clinical in nature, cases involving a

denial based on medical necessity, and cases involving denial of an expedited

resolution must be made by qualified clinical personnel, and health care

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

must be involved in the decision making process, and have been involved in the

provision of health care to the member in any way.

A file is contained on each grievance, which includes the date the grievance was

received at MPCS and a written copy of the grievance. The file also contains a

mailed and dated copy of acknowledgement letter, the grievance determination that

references the benefit provision, guideline, protocol, or other similar criterion on

which the decision is based, 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, qualifications,

specialties, and credentials of the personnel participating in the review.

Members must be allowed the opportunity before and during the grievance process

to examine their case file, including medical records and any other documents and

52




records, and obtain a copy of their appeal case free of charge if requested. Upon

request, MPCS will provide a written copy of the grievance procedure, readable at a

fourth grade level.

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) benefit

grievance that is being processed within standard time frames, 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. 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. The

period of time to make a grievance determination under Section 4904 of the Public

Health Law begins upon a health care plan’s receipt of necessary information. If

additional information is not received on intangible complaints (or non-benefit

related grievance), 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.

Grievance decisions not made within required time frames outlined in this section

will result in a reversal of the initial adverse determination.

Standard benefit related grievances for MMC, CHP, and HARP members are

decided within thirty (30) calendar days from receipt of the appeal, or as fast as the

member’s condition requires. Written notice of the standard grievance 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

below for requirements on content of notices).

Expedited resolution of a grievance must be conducted when MPCS 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. Members may also

request an expedited review. If MPCS denies the enrollee’s request for an expedited

review, MPCS must handle the request under standard resolution timeframes, make

53




reasonable efforts to provide prompt oral notice of the denial to the member, and

send written notice of the denial within two (2) days of the denial determination.

Expedited benefit related grievances for MMC, CHP, and HARP and verbal

notifications of such decisions must be made as fast as the member’s condition

requires, 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 below for requirements on notices.

For members with MMC & HARP contracts, the time frame for standard and

expedited grievances 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. MPCS maintains sufficient

documentation to demonstrate that the extension was justified. If additional

information is required to process the grievance, 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 below for requirements on content of extension notices.

For members with Essential Plan (commercial) insurance, if the initial or second

level benefit grievance relates to a pre-service matter, a decision and written notice

of the decision will be issued as fast as the member’s condition requires, but no later

than 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 as fast as the member’s condition

requires, but no later than 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 as fast as the member’s condition requires, but

no later than 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 as fast as the member’s condition

requires, but no later than thirty (30) calendar days of receipt of the grievance and

all necessary information.

Intangible grievances for Essential Plan, MMC, CHP, and HARP members must be

resolved and the member notified as fast as the member’s condition requires, but no

later than forty-five (45) calendar days after receipt of information, and no more

than sixty(60) days from receipt of the complaint. Written notice to follow within

three (3) business days. 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 as fast as the member’s condition requires, but no later

than forty-eight (48) hours after receipt of all necessary information (or in some

54




other form of communication if verbal notice is not possible) and no more than

seven (7) days from the receipt of the compliant.

Intangible grievances for Essential Plan, MMC, CHP, and HARP members must be

resolved and the member notified as fast as the member’s condition requires, but no

later than forty-five (45) calendar days after receipt of information, and no more

than sixty(60) days from receipt of the complaint. Written notice to follow within

three (3) business days. 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 as fast as the member’s condition requires, but no later

than 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.

o Written Notices of Standard & Expedited Grievances

All decisions generated during the standard and expedited grievance

process must be followed by written notices. Notice of action to

providers must contain the same information as notice of action to the

members.

Written notices generated during the appeals process, which include

determination notices, final adverse determination notices, and extension

must be dated and include the following:

Language must be easily understood, 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


Notices are also required to contain specific language depending on

the type of notice generated, which is outlined within the sections

below.


this section, written determinations and final adverse determination

notices for standard and expedited appeals must also include the

following. Note that notices of final adverse determinations for both

standard and expedited cases shall comply with all requirements of

Article 49 of the Public Health law and will all applicable federal

laws and rules.

The member and the nature of his/her medical

condition and the medical service, treatment or

procedure in question.

The reasons for the determination; provided, however,

that where the determination is adverse, the notice

shall include the clinical rationale for such

determination as applicable to the member..

55




A reference to the benefit provision, guideline,

protocol, or other similar criterion on which the appeal

decision is based.

For adverse decisions, a clear statement that the notice

constitutes a final adverse determination of either a

medical necessity or experimental or investigational

denial, which shall demonstrate that MPCS considered

enrollee-specific clinical information in its

determination.

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.

A contact person from MPCS and his/her telephone

number, the title, credentials, and qualifications

(including specialties) of individual(s) involved with

the appeal review, the name, full address, and

telephone number of the Plan’s utilization review

agent (if MPCS delegates appeals to an entity other

than MPCS), a contact person from the Plan’s

utilization review agent and his/her telephone

number(if MPCS delegates appeals to an entity other

than MPCS, and the member’s coverage type.

For adverse decisions, 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 external 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

56




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.

For adverse decisions regarding restrictions on MMC

members under MPCS ’s Restricted Recipient

Program (RRP), the notice must also 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.

For adverse decisions regarding Personal Care

Services for MMC members, the notice must also

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.

For adverse decisions regarding prescription

medications denials specified in section10.32 (g) of

the Medicaid Managed Care Model Contract, the

notice must also 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.


this section, notices to the member regarding a Plan-initiated

extension must include 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

57




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.

Sufficient documentation of the extension determination must be

maintained in order to demonstrate, upon NYSDOH request, that the

extension was justified.

Section 1557 Grievance Proceedings

It is the policy of MPCS not to discriminate on the basis of race, color, national

origin, sex, age or disability. MPCS has in place the below outlined internal

grievance procedures providing for prompt and equitable resolution of

complaints alleging any action prohibited by Section 1557 of the Affordable

Care Act (42 U.S.C. § 18116) and its implementing regulations at 45 C.F.R. pt.

92, issued by the U.S. Department of Health and Human Services. Section 1557

prohibits discrimination on the basis of race, color, national origin, sex, age or

disability in certain health programs and activities. Any person who believes

someone has been subjected to discrimination on the basis of race, color,

national origin, sex, age or disability may file a grievance under this procedure.

It is against the law for MPCS to retaliate against anyone who opposes

discrimination, files a grievance, or participates in the investigation of a

grievance.

Section 1557 and its implementing regulations may be examined in the office of

Kathleen Henehan, by mail at P.O. Box 240, Pittsford, N.Y. 14534; by

telephone at 1-800-683-3781 (for TTY/TDD services, call 1-877-200-2326)];

by fax at 1-888-273-8296; in person (or mail) at 1120 Pittsford-Victor Road,

Pittsford, N.Y. 14534, and by email at [email protected].

Grievances must be submitted to the Section 1557 Coordinator within (60 days)

of the date the person filing the grievance becomes aware of the alleged

discriminatory action. A complaint must be in writing, containing the name and

address of the person filing it. The complaint must state the problem or action

alleged to be discriminatory and the remedy or relief sought.

The Section 1557 Coordinator (or her/his designee) shall conduct an

investigation of the complaint. This investigation may be informal, but it will be

thorough, affording all interested persons an opportunity to submit evidence

relevant to the complaint. The Section 1557 Coordinator will maintain the files

and records of MPCS relating to such grievances. To the extent possible, and in

accordance with applicable law, the Section 1557 Coordinator will take

appropriate steps to preserve the confidentiality of files and records relating to

grievances and will share them only with those who have a need to know.

The Section 1557 Coordinator will issue a written decision on the grievance,

based on a preponderance of the evidence, no later than 30 days after its filing,


58




including a notice to the complainant of their right to pursue further

administrative or legal remedies. The person filing the grievance may appeal the

decision of the Section 1557 Coordinator by writing to the Chief Executive

Officer within 15 days of receiving the Section 1557 Coordinator’s decision.

The Chief Executive Officer shall issue a written decision in response to the

appeal no later than 30 days after its filing.

The availability and use of this grievance procedure does not prevent a person

from pursuing other legal or administrative remedies, including filing a

complaint of discrimination on the basis of race, color, national origin, sex, age

or disability in court or with the U.S. Department of Health and Human

Services, Office for Civil Rights. A person can file a complaint of discrimination

electronically through the Office for Civil Rights Complaint Portal, which is

available at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone

at:

U.S. Department of Health and Human Services.

200 Independence Avenue, SW

Room 509F, HHH Building

Washington, D.C. 20201

Complaint forms are available at: http://www.hhs.gov/ocr/office/file/index.html.

Such complaints must be filed within 180 days of the date of the alleged

discrimination. MPCS will make appropriate arrangements to ensure that

individuals with disabilities and individuals with limited English proficiency are

provided auxiliary aids and services or language assistance services,

respectively, if needed to participate in this grievance process. Such

arrangements may include, but are not limited to, providing qualified

interpreters, providing taped cassettes of material for individuals with low

vision, or assuring a barrier-free location for the proceedings. The Section 1557

Coordinator will be responsible for such arrangements.

Fair Hearing Procedures

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

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 MPCS 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.

http://www.hhs.gov/ocr/office/file/index.html

59




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.

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.

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

46

2017 MPCS Policies & Procedures

MMC, CHP, HAPR, and EP Contracts

Utilization Management Appeals & Grievances (Advocacy)

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

47






48




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

49




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.

When making prospective, concurrent and retrospective determinations , MPCS

shall collect only such information as is necessary to make such determination

and shall not routinely require health care providers to numerically code

diagnoses or procedures to be considered for certification or routinely request

copies of medical records of all patients reviewed. During prospective or

concurrent review, copies of medical records shall only be required when

necessary to verify that the health care services subject to such review are

medically necessary. In such cases, only the necessary or relevant sections of the

medical record shall be required. MPCS may request copies of partial or

complete medical records retrospectively.

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

50




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

51





entirety.

Oversight



52




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.

Additionally, MPCS is required to comply with all applicable provisions of the Fair Labor

Standards Act (FLSA). The Contractor shall develop protocols to demonstrate compliance

with requirements of the FLSA. Such protocols shall include appropriate record keeping

methodologies, tracking of aide travel time, hours worked on live-in cases, and appropriate

rate of reimbursement. Such verification system and protocols are subject to audit by DOH,

OMIG, and the Department of Labor.

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,

http://www.op.nysed.gov/opsearches.htm

53




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.

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.

54




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 MPCS 20 – UM Clinical

Peer Reviewers for vendors who offer clinical

peer reviewer services.

Director, 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 Director reports directly

to the Chief Operations Officer, and has an

indirect reporting relationship with the CMO.

This individual’s primary responsibility is to

ensure oversight of operations, which includes .

staff training and performance, 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


55




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

56




(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

57




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 Assistant/ Specialist Under the direction of the UM Manager, these

positions provide administrative support to the

UM Manager and department. The position(s)

also provides project support to other clinical

managers, the Chief Medical Officer, and the

Chief Operating Officer as required, manage the

collection of UM vendor data, and provide

operational support to UM vendors as needed.

This position cannot independently make

adverse medical necessity (including


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


58





The Chief Medical Officer, in collaboration with UM Management and the Human

Resource Department, is responsible for the tracking and oversight of this policy.

59




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 in accordance to applicable state and

federal laws. 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

60




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,

61




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


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.

62




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

63




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.

64




MPCS 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.

65




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 MPCS 02-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


entirety.

Oversight


oversight of this policy

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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



67




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.

68




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


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

69




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 &

70




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


entirety.

Oversight



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MPCS 19

UM & Advocacy [Appeals & Grievance (Complaints)] Programs

Quality Improvement Initiatives

Policy Statement

The overall quality and effectiveness of MPCS’ UM & Advocacy Programs are evaluated

and reported to MPCS’ UM & Advocacy Committee throughout the year using multiple

measures. The performance dashboard is a living document that serves as a tool for

reporting upon overall quality, compliance, and performance of the UM & Advocacy

services that MPCS is delegated to manage by their client health plans. These measures

are reported to the MPCS committee, and to MPCS’ client health plans in accordance to

the services that are delegated to MPCS to manage, and at a frequency determined by the

client health plan. All such measures are designed to ensure that program activities are

functioning at a level that help maintain, restore, or improve health outcomes of

individuals and populations. A summary of the quality, compliance, and performance

measures are provided below:

UM & Advocacy [Appeals,

Grievance (Complaints) ]

Volumes

& Timeliness Standards

Such measures track and ensure that time frames set forth

by state, federal, & accreditation bodies. 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 & Advocacy volumes are essential to

ensuring adequate staffing is available to manage all

service requests received in the department within required

time frames. Monthly time frame percentages are calculated

and reported upon to the committee and 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.

Both volume and timeliness metrics are reported to the

committee, and to the client health plan at a manner and

frequency dictated by the client health plan.

Case Management & Care

Coordination (CM)

Referral Volume

This measure tracks that members who meet specific triggers

are referred to case management for care coordination,

support, education, and resources relating to the condition(s)

in which members are receiving treatment for. To calculate

the percentage of cases appropriately referred to the CM

department, the volume of cases that are appropriately

referred is divided by the total number of referred cases.

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Trend Analysis Trend analysis is utilized to evaluate effectiveness of the

UR and Advocacy programs, and to identify areas of

improvement. 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 committee for

review.

Trends analyzed include, but are not limited to type of

reviews denied and approved through the UR & Advocacy

programs and over and under- utilization of services.

Member & Provider

Satisfaction Surveys as it

relates to the UR process

Member and provider satisfaction surveys are conducted on

an annual basis to determine overall satisfaction with the


MPCS uses data collected from the biannual New York

State Department of Health sponsored Consumer

Assessment of Healthcare Providers and Systems

(CAHPS) survey to measure member satisfaction from a

sampling of enrollees, as 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, all of 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 departmental staff, and

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

73




UM 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 across all review types and lines of businesses

managed by MPCS. 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 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 & Advocacy Chart

Audits

Chart auditing is essential to ensuring compliance to

state, federal, accreditation, and internal policies and

procedures on chart documentation

standards, letter requirements, review criteria, and

review priority. Two charts are

randomly selected from a pooling of all review types and

lines of businesses managed by MPCS 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 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

74




than 90% accuracy per chart reviewed, with an average

of 90% per month. A score less than 90% requires

remediation on the identified errors by Quality Specialist

and/or supervisor. A random chart completed on a date that

follows remediation to ensure reconciliation of the

identified error. If the same error is identified during

subsequent audits, disciplinary measures may be initiated.

A score of 95% or better is deemed as exceeding

expectations. Monthly chart audit scores are aggregated for

yearly total to include on performance reviews. See policy

titled UM & Advocacy Chart Audit Program for additional

details.

Member and Provider

Complaints (Grievances)

Complaints are investigated as they arise. MPCS uses the

definition of a complaint (or grievance) as outlined in New

York State Public Health Law 42 CFR 438.488 as a

guideline for what constitutes a compliant. 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 as fast as the enrollee’s

condition requires, but no later than then NYS timeliness

standards for complaint resolution, and addressed by the

most appropriately qualified staff person based on the

nature of the complaint. Complaints are 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 the committee for

review and feedback.

Complaints are reported to the client health at a frequency

dictated by the client health plan by review and service

type, volume, outcome, and timeliness of resolution. In

instances where MPCS is delegated to manage the formal

complaint process by the client health plan, MPCS partners

with the client health plan to report complaint metrics to the

New York State Department of Health (NYSDOH) through

the Health Commerce System (HCS) portal at the

frequency and in the format as required by the NYSDOH.

Program Goals &

Objectives

Yearly program goals and objectives are set forth each year

in efforts to maintain and/or improve upon program

performance. Progress towards meeting goals and

objectives are reported to the committee for feedback.

Performance Appraisals

The performance of all staff members are evaluated twice

annually using MPCS Human Resource policies and

procedures. Preferable outcomes for the annual evaluation

are Exceeds Expectations or Achieved Expectations. Staff

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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



76




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

Appendix A for vendor(s) that MPCS utilizes for 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

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standard UM protocols outlined in policy titled MPCS 02- UM Determination &

Notification Requirements.

Tracking Mechanism


entirety.

Oversight

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

for oversight of this policy.

Appendix A –Clinical Peer Reviewers

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.


78




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 activities 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

I. 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.

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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.

II. 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:

YourCare CMO (Internal Medicine), Chair

Psychiatrist

Pharmacist (Pharm.D)

80




Utilization Review Manager

Pharmacist representatives from ESI

Other specialty physicians/expert specialty reviews may be included on an as

needed basis.

III. 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.

Utilization management programs such as prior authorization, step‐edits,

MD‐edits, quantity limits, and age limits will be applied to promote

appropriate utilization.

A “Formulary Exception” process will be readily available, easy to use, and

timely.

A “Transition of Care” policy will be available to assist members

transitioning to YCHP.

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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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MPCS 22

LTSS Services

Policy Statement

Long Term Services and Supports (LTSS) include the services and supports used by

Enrollees with functional limitations and chronic illnesses who need assistance to

perform routine daily activities such as bathing, dressing, preparing meals, and

administering medications. Such services may be home or community based or provided

in institutional settings, and are provided when medically necessary to enable members to

live safely in the most integrated and least restrictive setting.

Community Based Long Term Services are provided in the home or community setting

(any place of residence, either permanent or temporary, other than a hospital, skilled

nursing home, or health related facility) and include Private Duty Nursing, Skilled

Nursing, Home Health Services, Personal Care Services, Consumer Directed Personal

Assistance Services, Adult Day Health Care, and AIDS Adult Day Health Care.

Institutional Long Term Services and Supports are Residential Health Care Facility

(RHCF) services, and non-residential inpatient acute care services, where it is

anticipated that upon discharge, the member will be in need of RHCF services or

Community Based LTSS.

Procedure

1. Identifying Members in Need of LTSS

When MPCS identifies a member who is expected, as demonstrated by

an assessment or provider order, to be in receipt of LTSS for less than 120 days, MPCS

will arrange for all medically necessary covered services as required, and provide care

management services where MPCS determines, or the member’s provider states, care

management services are necessary due to the member’s condition. MPCS shall identify

members who will require more than 120 days of LTSS from the disenrollment file, as

those members are eligible for MLTC. Within 5 business days of receipt of the

disenrollment file, MPCS transmit the results of the file match, in a format to be

determined by SDOH, to the Enrollment Broker or LDSS.

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MPCS will have appropriate mechanisms to identify new members in receipt

of LTSS to ensure these members are referred or otherwise engaged by MPCS’ care

management process. Such mechanisms may include, but are not limited to, the use of

welcome letters and initial health screenings to encourage members in receipt of LTSS to

contact MPCS, outreach to auto-assigned members, establishing a liaison for

communication with the LDSS and other MMC plans regarding the member’s PCSP,

communication with participating providers to encourage prompt notification to MPCS of

new members in receipt of LTSS, and identification of service authorization requests for

LTSS absent a PCSP.

MPCS will have appropriate mechanisms to ensure members newly in need of

LTSS are referred or otherwise engaged by MPCS’ care management process.

Such mechanisms may include, but are not limited to, coordination with discharge

planners, establishing a liaison with key participating providers, developing

linkages with member services and/or complaint staff, and protocols linking review of

service authorization requests for LTSS to the care management process.

2. LTSS Authorization Standards and Review Processes

MPCS will ensure covered LTSS services are authorized in an amount,

duration, and scope to meet the needs of the member pursuant to the PCSP. The

following criteria is utilized for making service authorizations on the below LTSS

services. UM staff follow MPCS 02- UM Determination & Notification Requirements for

guidelines on timeliness for utilization determinations and verbal and written

notifications of service authorization requests.

Private Duty Nursing- NYS Medicaid Private Duty Nursing Prior Approval

Manual (https://www.emedny.org/ProviderManuals/NursingServices/index.aspx)

See also MPCS PPM titled UM Procedure- Private Duty Nursing

Consumer Directed Personal Assistance Services (CDPAS) - 18 NYCRR Part

505.28, Appendix S of the NYS Medicaid Managed Care contract, and NYSDOH

Guidelines for Consumer Directed Personal Assistance Services

(https://www.emedny.org/ProviderManuals/PersonalCare/index.aspx)

Personal Care Services (PCS/PCA) - 18 NYCRR §505.14(a), Appendix S of the

NYS Medicaid Managed Care contract, and NYSDOH Guidelines for the

Provision of Personal Care Services

(https://www.emedny.org/ProviderManuals/PersonalCare/index.aspx)

Residential Health Care Facilities - Appendix S of the NYS Medicaid Managed

Care contract, and the NYSDOH Transition of Nursing Home Benefit and

Population into Managed Care policy

(https://www.emedny.org/ProviderManuals/ResidentialHealth/index.aspx)

Home Care Services - Interqual Level of Care Criteria for Home Care. See also

NYS Rehabilitation Services Manual

(https://www.emedny.org/ProviderManuals/RehabilitationSrvcs/index.aspx)

Adult Day Health Care (ADHC) and AIDS Adult Day Health Care (AIDS

https://www.emedny.org/ProviderManuals/NursingServices/index.aspx

https://www.emedny.org/ProviderManuals/PersonalCare/index.aspx

https://www.emedny.org/ProviderManuals/PersonalCare/index.aspx

https://www.emedny.org/ProviderManuals/ResidentialHealth/index.aspx

https://www.emedny.org/ProviderManuals/RehabilitationSrvcs/index.aspx

84




ADHC) - Appendix S of the NYS Medicaid Managed Care contract, NYSDOH

Guidelines for the Transition of Adult Day Health Care and AIDS Adult Day

Health Care Services in Medicaid Managed Care (as defined in 10 NYCRR §

425.1 and 759). See also PPM titled UM Procedure - MP CareSolutions (MPCS)

2017 Policies & Procedures for Management of Medicaid Managed Care, Child

Health Plus, Health & Recovery Plan, Essential Plan Contracts -Utilization

Managment & Advocacy

MPCS shall not reduce or terminate LTSS unless:

There has been, as demonstrated by an assessment or provider’s order, a change in

the member’s medical condition, environment, assistive technology, or informal

supports.

The member no longer meets the statutory or regulatory criteria for provision of

the service.

The member requests a reduction or change in service.

There was a documented error in the information that MPCS relied upon for the

initial authorization.

The conditions of INSL §3238 or 10 NYCRR §98-1.13(n) have been met.

If MPCS determines to reduce the level or amount of LTSS, MPCS

must ensure that all needs identified in the PCSP are still appropriately addressed,

including authorization for assistance with activities of daily living that may have

been previously provided to the member incidentally under a higher or more intense

level of service.

In accordance with section F.1(4)(b) of Appendix F of the Medicaid Managed Care

contract, MPCS shall ensure the Notice of Action is sent to the Enrollee and provider at

least ten (10) days prior to the effective date of an Action that reduces, suspends

or terminates LTSS, and that such effective date does not fall on a non-working

day, unless MPCS provides “live” telephone coverage available on a

twenty-four (24) hour, seven day a week basis to accept and respond to

Complaints, Complaint Appeals and Action Appeals, in a manner that considers

the safety of the member.

Consistent with Section 10.37 and Appendix K of the Medicaid Managed Care contract,

if services at an alternate level of care are not immediately available, MPCS shall

ensure continued authorization of LTSS as needed until safe discharge/transition

can be effectuated.

MPCS will make reasonable efforts to effectively communicate with

providers and members during the PCSP development process regarding the need to

obtain authorization for the services included in the PCSP, the timing of such reviews

and when MPCS has made its determination, so as to facilitate understanding

of when any disagreements among the care planning team are to be resolved through

MPCS’ grievance system.

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Pursuant to Appendix F of the Medicaid Managed Care contract, MPCS will provide

timely notice of all Actions to the member and their provider, including notice of the

member’s right to appeal the Action, and right to request a State fair hearing and

right to aid continuing as per Section 25 of the Medicaid Managed Care contract.

3. Care Management for LTSS

Please note that MPCS UM staff are required to refer those members receiving LTSS

services to MPCS Care Management staff. The MPCS Care Management staff are then

responsible for the provision of the following care management requirements, and MPCS

UM staff are not involved in any other aspect of the care management process as outlined

below.

Care management means a process that assists members in accessing necessary

covered services as identified in the Person Centered Services Plan (PCSP). A PCSP is

required for all members using Long-Term Services and Supports. MPCS will ensure

LTSS are provided in accordance with Appendix S of the Medicaid Managed Care

contract.

Care management services include referral, assistance in or coordination of services for

members to obtain needed medical, social, educational, psychosocial, financial and other

services in support of the PCSP, irrespective of whether the needed services are included

in the Benefit Package.

MPCS shall have appropriate organizational structure and mechanisms, which may take

the form of dedicated units or staff, to provide care management services to members in

receipt of LTSS.

Through its care management process, the MPCS will ensure the following:

Facilitate structural linkages with member services, complaint, and service

authorization functions to ensure prompt response to members request for

assistance in accessing LTSS

Maintain records of members currently in receipt of LTSS, coordination of PCSP

development in accordance with Section 10.35 of the Medicaid Managed Care

Contract, including reassessment and update of the PCSP as warranted by the

member’s condition but in any event at least once every six (6) months.

Coordinate with health care professionals, discharge planners and provider care

teams to facilitate member transitions between levels of care

Facilitate structural linkages with utilization review functions to authorize

medically necessary covered services in accordance with an approved PCSP and

Appendix F of the Medicaid Managed Care Contract

Refer members in receipt of LTSS to case management and coordinate with case

management to implement approved PCSP.

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Inform members of CDPAS options, and refer members to New York State Home

and Community Based Services waiver programs and other community resources

as needed.

Maintain routine contact with members in receipt of LTSS commensurate with

the needs of the members, which may be satisfied by one care management

telephone contact per month. However, MPCS shall conduct at least one facility

or home visit every 6 months, which may be combined with scheduled

assessments.

Notify LDSS when a member in receipt of LTSS no longer appears on the roster,

and transmit the PCSP and other needed documentation to the LDSS and

to the member’s new MMC plan, if known, to minimize disruption of LTSS.

Ensure that the level and degree of care management provided, in conjunction to

the PCSP, addresses the member’s needs and are based upon the acuity and

severity of the member’s physical and mental condition. The potential that an

member may require intermittent acute hospital inpatient services shall not

be taken into consideration by MPCS when assessing a member’s need for care

management of LTSS.

Develop written operational policies and procedures and automated systems in

support of care management functions.

Ensure that staff responsible for care management have appropriate experience (as

determined by MPCS) in health care, social work, nursing and/or long term care,

and are trained in MPCS procedures.

Ensure that MPCS has sufficient staff capacity to carry out care management

functions for the enrolled population utilizing LTSS. If care management is

provided via a team approach, MPCS must ensure its policies and procedures

describe responsibilities of team members and how the team is to

carry out care management functions.

4. LTSS Transitional Care

With regards to transitional care of members receiving LTSS service, MPCS will

ensure the following:

Notwithstanding any benefit or population-specific Fee For Service (FFS) to

MMC transitional care policy described in the Medicaid Managed Care contract,

MPCS will authorize and cover LTSS at the same level, scope, and amount as

the member received under the FFS program for 90 days following enrollment or

until the member’s PCSP is in place, whichever is later.

Except where a participating provider agreement describes an alternate

arrangement for authorization of transitional care, MPCS may not deny

payment to providers of transitional care LTSS solely on the basis that the

provider failed to request prior authorization.

Where an existing medical order has or is about to expire, and a new medical

order is required for the continued provision of LTSS during the transitional

period but cannot be obtained after reasonable effort, MPCS shall work

87




with the LTSS provider to arrange a safe transition for the member, which may

be to higher level of care.

MPCS will provide transitional care services pursuant to Section 15.6(a)(i) of the

Medicaid Managed Care contract and the SDOH Medicaid Managed Care and

Family Health Plus Coverage policy titled New Managed Care Enrollees in

Receipt of an On-going Course of Treatment.

5. Critical Incidents

MPCS must have effective mechanisms to identify, address and seek

to prevent instances of abuse, neglect and exploitation of its members in

receipt of Long Term Services and Supports on a continuous basis. Such

mechanisms will include, at a minimum:

A process to include information in education materials distributed to

members and providers to enable reporting of such instances to MPCS or providing

available community resources for member’s assistance.

Provisions in subcontracts to ensure providers of long term services and

supports comply with NYS requirements for worker criminal background checks.

Identification of critical incidents, including but not limited to, wrongful death,

restraints, and medication errors resulting in injury,which are brought to MPCS’

attention, and subsequent investigation or referral of the incidents to oversight

agencies.

Reporting critical incidents to SDOH as provided by Section 18.5(a)(vi)(D) of the

Medicaid Managed Care contract.

Tracking Mechanism


entirety.

Oversight

