Utilization Management Appeal Process and Timeframes for ...

Pre-certification (urgent): A request for a health care service or course of treatment for whichthe time period for making a non-urgent care request determination (A) could seriously jeopardizethe life or health of the covered person or the ability of the covered person to regain maximumfunction, or (B) in the opinion of a health care professional with knowledge of the coveredperson's medical condition, would subject the covered person to severe pain that cannot beadequately managed without the health care service or treatment being requested.Prospective Review: Utilization review conducted prior to an admission or the provision of ahealth care service or a course of treatment.Recission: Cancellation or discontinuance of coverage under a health benefit plan that has aretroactive effect, after a Member becomes sick or is injured.Retrospective (post-service) Review: Utilization review of a request for medical services,supplies or equipment on a case-by-case or aggregate basis after services, supplies orequipment have been provided, such as a claim for services that have already been rendered.Urgent Request: A request for a health care service or course of treatment for which the timeperiod for making a non-urgent care request determination (A) could seriously jeopardize the lifeor health of the covered person or the ability of the covered person to regain maximum function,or (B) in the opinion of a health care professional with knowledge of the covered person's medicalcondition, would subject the covered person to severe pain that cannot be adequately managedwithout the health care service or treatment being requested. When determining whether abenefit request shall be considered an urgent care request, an individual acting on behalf of ahealth carrier shall apply the judgment of a prudent layperson who possesses an averageknowledge of health and medicine, except that any benefit request determined to be an urgentcare request by a health care professional with knowledge of the covered person's medicalcondition shall be deemed an urgent care request.Utilization Review: the use of a set of formal techniques designed to monitor the use of, orevaluate the medical necessity, appropriateness, efficacy or efficiency of, health care services,health care procedures or health care settings. Such techniques may include the monitoring of orevaluation of (A) health care services performed or provided in an outpatient setting, (B) theformal process for determining, prior to discharge from a facility, the coordination andmanagement of the care that a patient receives following discharge from a facility, (C)opportunities or requirements to obtain a clinical evaluation by a health care professional otherthan the one originally making a recommendation for a proposed health care service, (D)coordinated sets of activities conducted for individual patient management of serious,complicated, protracted or other health conditions, or (E) prospective review, concurrent review,retrospective review or certification.POLICYWho can submit an appeal:1. A Claimant can initiate an appeal. A Claimant includes:o Membero Member's physician with the Member's consento Member's designee or agent (relative, friend or attorney, etc.)The Member must provide Oxford with the designation, in writing, at the time of theappeal. The designation must be signed by the Member, or by the Member's guardian, ifthe Member is a minor.2. Participating Provider AppealUtilization Management Appeal Process and Timeframes for Connecticut Plans: Administrative Policy(Effective 06/11/2013)3©1996-2013, Oxford Health Plans, LLC

Participating providers including professional and institutional providers. These appealsare made consistent with the participating provider's contractual obligations with Oxfordand are not done on behalf of the Member.Initiating an Internal Appeal:There are several methods for submitting an internal appeal.I. In Writingo First Level Appeal:Oxford Health PlansAttn: Clinical Appeals DepartmentP.O. Box 29139Hot Springs, AR 71903Fax: (877) 220-7537oSecond Level Appeal:Oxford Health PlansAttn: Grievance Review BoardP.O. Box 29134Hot Springs, AR 71903Fax: 866-352-6053II.Verballyo Members: (800) 444-6222o Providers: (800) 666-1353The Clinical Appeals Department and the Grievance Review Board will make all attempts whenpossible to notify the initiator, in writing, within 5 business days of receipt of the appeal request.An acknowledgment letter will be sent by mail stating that the request for appeal has beenreceived, it is currently being reviewed, and that the initiator will be notified of the outcome.Procedural Failure: If a request is not sent to the correct department or address, Oxford mustnotify the covered person of the failure within five days after receiving the request for a nonurgentrequest or within 24 hours for an urgent care request. Oxford may provide the noticeorally, with written confirmation within five days after providing the oral notice.PROCEDURES AND RESPONSIBILITESAppeals rights vary depending on whether it is initiated by the Member or by the provider. Inaddition, state regulations require different timeframes to be adhered to depending on the level ofappeal. All levels of appeal require Oxford to make all attempts when possible to notify theinitiator of receipt of the request, in writing, within 5 business days of receipt of the appealrequest.Participating Providers/Facilities appealing regarding Connecticut plan Members:• Timeframe for Submission of an Appeal: Participating providers/facilities have 180days from the initial adverse determination notification, either verbally or by writtennotification of non-certification, End of Day report issued by Medical Management orExplanation of Benefit statement.Utilization Management Appeal Process and Timeframes for Connecticut Plans: Administrative Policy(Effective 06/11/2013)4©1996-2013, Oxford Health Plans, LLC

• Levels of Appeal: Participating providers/facilities have only one level of appeal.Oxford's Clinical Appeals Department will perform a full, clinical review of all pertinentdata, including medical records, photos and peer review. This is the final decision for allparticipating facilities.• Decision Timeframe for 1st level Appeals: Participating providers/facilities will benotified in writing of the decision within 60 days from receipt of an appeal and supportingdocumentation. Full documentation of the substance of the appeal and the actions takenwill be maintained in an appeal file.Member Appeals - Members of Connecticut plans or the authorized designee appealing onbehalf of the Member.1. First Level Internal Appeal: Clinical Appeals DepartmentTimeframe for Submission of an Appeal:Oxford grants all Members 180-calendar days following the Claimant'snotification of the initial adverse Utilization Management determination (verbal orwritten notification of non-certification or Explanation of Benefit statement).Clinical Review:Will make all attempts when possible to acknowledge the receipt of the Member'sappeal within 5 business days of receipt of the appeal request or respond withinthis time frame.Oxford will conduct a review of the appeal in a manner to ensure theindependence and impartiality of the individual(s) involved in making the reviewdecision and that does not give regard to the denial decision. Clinical Appeals willfully investigate the substance of the appeal, including any aspects of clinicalcare involved. The Member will be given an opportunity to submit writtencomments, documents, medical records, photos, peer review or other informationrelevant to the appeal. The individual(s) conducting the review of the appeal willtake into consideration all comments, documents, records and other informationrelevant to the Member's request, regardless of whether such information wassubmitted or considered in making the initial adverse determination.Oxford will appoint an individual to review the appeal who was not involved in theinitial decision and is not a subordinate of any person involved in the initialdetermination. In addition, the person appointed to review the appeal would be apractitioner in the same or similar specialty who typically treats the medicalcondition, performs the procedure or provides the treatment. All CT commercialplan Members, including self-funded Members* are entitled to this level. This isthe final decision made by Oxford for all self-funded Members unless otherwiserequested by the self-funded plan.*Employees of the State of Connecticut may file an external appeal through theState of Connecticut Department of Insurance. Please refer to the section belowtitled “Member External Appeal Level.”Decision Timeframe for First Level AppealsThe time period begins on the date Oxford receives the grievance, regardless ofwhether all of the information necessary to make the decision accompanies thefiling.Utilization Management Appeal Process and Timeframes for Connecticut Plans: Administrative Policy(Effective 06/11/2013)5©1996-2013, Oxford Health Plans, LLC

Oxford must make an appeal determination and notify the Member in writing orelectronically within:• 30 calendar days from receipt of a prospective or concurrent serviceappeal• 60 calendar days from receipt of a post-service appealThe resolution timeframe is calculated from the receipt of the request for a firstlevel appeal. Full documentation of the substance of the appeal, including anyaspects of clinical care involved and the actions taken, will be maintained in anappeal file.Strict Adherence Required:If Oxford fails to adhere to timeframe requirements on the First Level Appeal, theMember is deemed to have exhausted Oxford's internal grievance process andmay file an external review, regardless of whether Oxford could assertsubstantial compliance or deminimis error.Oxford shall provide continued coverage of an ongoing course of treatmentpending the outcome of the Stage 1 internal appeal.New or Additional Evidence:Before issuing a decision, Oxford must provide free of charge, by facsimile,electronic means or any other expeditious method available, to the Member anynew or additional documents, communications, information and evidence reliedupon or scientific or clinical rationale used in connection with the grievance.Oxford must provide such documents, communications, information, evidenceand rationale sufficiently in advance of its determination date to allow theMember a reasonable opportunity to respond before that date.Written Appeal Decisions:Written appeal decisions must include the following elements, when applicable:oooooSufficient information to identify the benefit request or claim involved, includingthe date of service, health care professional, and claim amount.A statement of Clinical Appeals' understanding of the Member's appeal.The specific reasons for the appeal decision in easily understandable language,including the denial code and its corresponding meaning.A reference to the scientific or clinical criteria, benefit provision, guideline,protocol or other similar criterion on which the appeal decision was based, aswell as written notification that the Member, upon request and free of charge, isallowed access to and copies of all relevant documentation, records,communications and other information and evidence not previously providedregarding the Member's appeal. Refer to Disclosure Policy. A list of titles andqualifications of individuals participating in the appeal review (participant namesdo not need to be included in the written notification to Members).A description of the next level of appeal, either the voluntary, internal appealwithin the organization or to an external organization, as applicable, along withany relevant written procedures.Utilization Management Appeal Process and Timeframes for Connecticut Plans: Administrative Policy(Effective 06/11/2013)6©1996-2013, Oxford Health Plans, LLC

ooA statement disclosing the Member's right to contact the InsuranceCommissioner or the Health Care Advocate at any time and their contactinformation.A statement describing the procedures for obtaining an external review of thefinal adverse determination.When applicable, the written appeal decision notice will include the following statement:"You and your plan may have other voluntary alternative dispute resolution options suchas mediation. One way to find out what may be available is to contact your stateInsurance Commissioner."The notice will also include a statement disclosing the Member's right to contact thecommissioner's office or the Office of the Healthcare Advocate at any time. Thesestatements will include the current contact information for both offices.After all internal levels of appeals have been exhausted (Levels 1 and 2), the Memberhas the right to file a civil action under 502(a) of the Employee Retirement IncomeSecurity Act (ERISA). ERISA rights apply to all Connecticut plans except individuals,church groups and municipalities.2. Voluntary Second Level: Grievance Review BoardoWhen a First Level UM appeal is denied, the member will receive a denial fromOxford's Clinical Appeals Department, which will provide the member with theoption of submitting:• an external appeal (refer to # 3 below); or• a voluntary, internal Second Level of appealooTimeframe for Submission of a Written Appeal to the Grievance ReviewBoard:Members have 60 calendar days from the First Level utilization managementappeal determinations to submit an appeal to the Grievance Review Board.Grievance Review:The Second Level Appeal process whereby any Member or any provider actingon behalf of a Member with the Member's consent, who is dissatisfied with theresults of the First Level appeal, shall have the opportunity to pursue his or herappeal by submitting a written appeal.Oxford will conduct a review of the appeal in a manner to ensure theindependence and Impartiality of the individual(s) involved in making the reviewdecision and that does not give deference to the denial decision. Oxford will fullyinvestigate the substance of the appeal, including any aspects of clinical careinvolved. The Member will be given an opportunity to submit written comments,documents, medical records, photos, peer review or other information relevant tothe Member's appeal to the Grievance Review Board. The Grievance ReviewBoard (GRB) is a team of Oxford employees not involved in the initialdetermination and who are not the subordinate of any person involved in theinitial determination appointed for the express purpose of reviewing and resolvingMember appeals.The individual(s) conducting the review of the appeal will take into considerationall comments, documents, records and other information relevant to theUtilization Management Appeal Process and Timeframes for Connecticut Plans: Administrative Policy(Effective 06/11/2013)7©1996-2013, Oxford Health Plans, LLC

Member's request, regardless of whether such information was submitted orconsidered in making the initial adverse determination.When an appeal is clinical in nature, the GRB will include a licensed physicianwho did not review the issue at the First Level Appeal. If the appeal pertains toan administrative issue, individuals of a "higher level" than those who reviewedthe First Level Appeal will resolve the Second Level Appeal. In addition, one ofthe persons appointed to review an appeal involving clinical issues is apractitioner in the same or similar specialty who typically treats the medicalcondition, performs the procedure or provides the treatment.Oxford shall provide continued coverage of an ongoing course of treatmentpending the outcome of the Stage 2 internal appeal.New or Additional Evidence:Before issuing a decision, Oxford must provide free of charge, by facsimile,electronic means or any other expeditious method available, to the Member anynew or additional documents, communications, information and evidence reliedupon or scientific or clinical rationale used in connection with the grievance.Oxford must provide such documents, communications, information, evidenceand rationale sufficiently in advance of its determination date to allow theMember a reasonable opportunity to respond before that date.Decision Timeframe for Grievance Review Board• 15 calendar days from the receipt of a pre-service appeal• 30 calendar days from the receipt of a post-service appealooStrict Adherence Required:If Oxford fails to adhere to timeframe requirements on the Second Level Appeal,the Member is deemed to have exhausted Oxford's internal grievance processand may file an external review, regardless of whether Oxford could assertsubstantial compliance or deminimis error.Written appeal decisions:Written appeal decisions must include the following elements, when applicable:• Sufficient information to identify the benefit request or claim involved,including the date of service, health care professional, and claim amount.• A statement of GRB's understanding of the Member's appeal.• The specific reasons for the appeal decision in easily understandablelanguage, including the denial code and its corresponding meaning.• A reference to the scientific or clinical criteria, benefit provision,guideline, protocol or other similar criterion on which the appeal decisionwas based, as well as written notification that the Member, upon requestand free of charge, is allowed access to and copies of all relevantdocumentation, records, communications and other information andevidence not previously provided regarding the Member's appeal. Referto policy: Disclosure Policy. A list of titles and qualifications of individualsparticipating in the appeal review (participant names do not need to beincluded in the written notification to Members).• A description of the next level of appeal, either within the organization orto an external organization, as applicable, along with any relevant writtenprocedures.Utilization Management Appeal Process and Timeframes for Connecticut Plans: Administrative Policy(Effective 06/11/2013)8©1996-2013, Oxford Health Plans, LLC

• A statement disclosing the Member's right to contact the InsuranceCommissioner or the Health Care Advocate at any time and their contactinformation.• A statement describing the procedures for obtaining an external reviewof the final adverse determination.When applicable, the written appeal decision notice will include the followingstatement: "You and your plan may have other voluntary alternative disputeresolution options such as mediation. One way to find out what may be availableis to contact your state Insurance Commissioner."The notice will also include a statement disclosing the Member's right to contactthe commissioner's office or the Office of the Healthcare Advocate at any time.These statements will include the current contact information for both offices.After all internal levels of appeals have been exhausted (First Level and SecondLevel), the Member has the right to file a civil action under 502(a) of theEmployee Retirement Income Security Act (ERISA). ERISA rights apply to allConnecticut plans except individuals, church groups and municipalities.2. Member External Appeal LevelNote: For expedited external appeals, please refer to policy: Expedited Appeal Process.Clinical review conducted by an external agent of the appropriate state. Information onhow to submit an external appeal is outlined in the initial denial letter and all subsequentappeal decision letters. All Connecticut commercial plan Members (except self-funded*)are entitled to this level, after he or she has completed the first level, internal grievanceprocess. However, the enrollee may be able to request the external review prior toexhausting the internal appeals process if the health carrier agrees to waive the internalappeals process.* Employees of the State of Connecticut may file an external appeal through the State ofConnecticut Insurance Department. All other self-funded groups do not have externalappeal rights.Submission timeframe: The submission of an external appeal to the State ofConnecticut Insurance Commissioner must be done within 120 calendar days from thedate of receipt of the adverse determination or Grievance Review Board Decision. ForRhode Island residents who are Members of Connecticut plans and choose to utilize theState of Rhode Island external appeal process, submission of an external appeal toOxford must be done within 120 calendar days from the date of receipt of the GrievanceReview Board Decision.Preliminary Review: Within five business days after receiving a copy of a standardexternal review request for the State of Connecticut Insurance Commissioner, onecalendar day after receiving a copy of an expedited external review request, Oxford mustcomplete a preliminary review to determine whether:1. The enrollee was a covered person under the health benefit plan at the time thehealth care service was requested or provided;2. The involved health care service is a covered service under the covered person'shealth benefit plan except for the health carrier's determination that it does notmeet its requirements for medical necessity, appropriateness, health care setting,level of care, or effectiveness;Utilization Management Appeal Process and Timeframes for Connecticut Plans: Administrative Policy(Effective 06/11/2013)9©1996-2013, Oxford Health Plans, LLC

3. The covered person has exhausted the health carrier's internal grievanceprocess or filed an expedited external review request; and4. The covered person has provided all the information and forms required toprocess a standard or expedited external review. If the service or treatment isexperimental or investigational, the health carrier must also determine whether:• the requested health care treatment that is the subject of thedetermination (a) is a covered benefit under the enrollee's health benefitplan except for the health carrier's determination that the service ortreatment is experimental or investigational and (b) is not explicitlyexcluded under the enrollee's health benefit plan;• the enrollee's treating health care professional has certified that (a)standard health care treatments have not been effective in improving thecovered person's medical condition, (b) standard health care treatmentsare not medically appropriate for the person, or (c) there is no availablestandard health care treatment covered by the health carrier that is morebeneficial than the requested health care treatment; and• the enrollee's treating health care professional (a) has recommended ahealth care treatment that he or she certifies, in writing, is likely to bemore beneficial to the enrollee than any available standard health caretreatments or (b) is a licensed, board certified, or board eligible healthcare professional qualified to practice in the area of medicine appropriateto treat the enrollee's condition and has certified, in writing, thatscientifically valid studies using accepted protocols demonstrate that thehealth care treatment the covered person requested is likely to be morebeneficial than any available standard health care treatments.Oxford must notify the Commissioner and the enrollee in writing on whether the requestis complete and eligible for external review within one business day after completing thepreliminary review for a standard external review request or on the day the preliminaryreport is completed for an expedited external review request. The Commissioner mayspecify the form for the health carrier's initial determination notice.If the request is not complete, Oxford's notice must specify the information needed toperfect the request. If the request is not eligible for standard or expedited external review,the notice must include the reasons for its ineligibility.The notice must include a statement informing the enrollee that he or she can appeal thisdetermination to the Commissioner. Regardless of a health carrier's initial determinationthat a request for a standard or expedited external review is ineligible for review, theCommissioner may determine, pursuant to the terms of the enrollee's health benefit plan,that the request is eligible and assign an independent review organization to conduct it.Within one business day, for a standard external review request, or one calendar day, foran expedited external review request, of receiving notice that a request is eligible forreview, the State of Connecticut Insurance Commissioner must (1) assign anindependent review organization to conduct the review (randomly from among qualifiedorganizations), (2) notify the health carrier of the organization's name, and (3) notify theenrollee in writing of the eligibility and acceptance for review. The written notice mustinclude (1) a statement that the enrollee may submit, within five business days afterreceiving the notice, additional information in writing to the organization for considerationand (2) where and how such additional information must be submitted. If additionalinformation is submitted later than five business days after the covered person receivedthe notice, the organization may, but is not be required to, accept and consider it.Health Carrier - Providing InformationWithin five business days for a standard external review and one calendar day for anexpedited external review after receiving the name of the assigned independent review10Utilization Management Appeal Process and Timeframes for Connecticut Plans: Administrative Policy(Effective 06/11/2013)©1996-2013, Oxford Health Plans, LLC

organization, Oxford must provide the organization any information it considered inmaking the determination under review.If Oxford fails to timely provide the information, the organization (1) must not delayperforming the review and (2) may terminate the review and make a decision to reversethe determination. Within one business day after terminating the review and deciding toreverse the determination, the organization must notify the commissioner, Oxford, andenrollee in writing.Independent Review Organization - Receipt of New InformationThe organization must review all the information received from the enrollee and Oxford.In reaching a decision, the organization is not bound by any decisions reached during theOxford's utilization review process. Upon receiving any new information from the coveredperson, the organization has one business day to forward it to the health carrier.If the enrollee submits new information, Oxford will have the opportunity to review theinformation and reconsider the original decision. This reconsideration will not delay theexternal review. However, if Oxford decides to reverse its original denial, Oxford has 1business day to notify the Commissioner, independent review organization and theenrollee of the reversal. At this point, the external review will be terminated.Oxford shall provide continued coverage of an ongoing course of treatment pending theoutcome of the Stage 3 External appeal.Decision timeframe: The external review agent will render a decision for standardexternal reviews, 45 days; standard external reviews involving an experimental orinvestigational treatment or service, 20 days; expedited external reviews, 72 hours; andexpedited external reviews involving an experimental or investigational treatment orservice, five days.oFor Rhode Island residents who are Members of Connecticut plans and havechosen to utilize the State of Rhode Island external appeal process, decisionsfrom the external reviewer must be made within 10 business days of the requestfor standard external appeals and within 2 business days of the request forexpedited external appeals. This is the final decision for all CommercialMembers.REFERENCESC.G.S.A. § 38a-226c and §38a-478n.Regulations of the Connecticut State Agencies Sections 38a-226c-1 et seq. and 38a-487n-3-2 etseq.General Laws of Rhode Island Annotated §23-17.12-10.Rhode Island Department of Health Rules and Regulations for the Utilization Review of HealthCare Services (R23-17.12-UR).NCQA Guidelines.Department of Labor Regulations 29 CFR 2560.503.1.CT Public Act 11-58Utilization Management Appeal Process and Timeframes for Connecticut Plans: Administrative Policy(Effective 06/11/2013)11©1996-2013, Oxford Health Plans, LLC

CT Public Act 12-102Connecticut Public Act 13-3POLICY HISTORY/REVISION INFORMATIONDate06/11/2013Action/Description• Updated guidelines for Decision Timeframes for First LevelAppeals; added language to indicate Oxford shall providecontinued coverage of an ongoing course of treatmentpending the outcome of the Stage 1 internal appeal• Updated guidelines for Decision Timeframes for VoluntarySecond Level Appeals; added language to indicate Oxfordshall provide continued coverage of an ongoing course oftreatment pending the outcome of the Stage 2 internalappeal• Updated guidelines for Decision Timeframes for MemberExternal Appeals; added language to indicate Oxford shallprovide continued coverage of an ongoing course oftreatment pending the outcome of the Stage 3 externalappeal• Archived previous policy version APPEALS 021.12Utilization Management Appeal Process and Timeframes for Connecticut Plans: Administrative Policy(Effective 06/11/2013)12©1996-2013, Oxford Health Plans, LLC