Utilization Management Appeal Process and Timeframes for ...

• 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