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