Utilization Management Appeal Process and Timeframes for ...

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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
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