CALIFORNIA - Pacificare Health Systems

PART A
112
Overseeing Your Health Care
PacifiCare and Participating Medical Groups notify
requesting Providers of decisions to approve, modify or
deny requests for authorization of health care services
for Members within 24 hours of the decision. Members
are notified of decisions to deny, delay or modify
requested health care services, in writing, within two
business days of the decision. The written decision will
include the specific reason or reasons for the decision
the clinical reason or reasons for modifications or
denials based on a lack of Medical Necessity and
information about how to file an appeal of the decision
with PacifiCare. In addition, the internal criteria or
benefit interpretation policy, if any, relied upon in
making this decision will be made available upon
request by the Member. PacifiCare’s Appeals Process is
outlined in the “General Information” section of this
Combined Evidence of Coverage and Disclosure Form.
If the Member requests an extension of a previously
authorized and currently ongoing course of treatment,
and the request is an “Urgent Request,” as defined
above, PacifiCare or its Participating Medical Group
will approve, modify or deny the request as soon
as possible, taking into account the Member’s
medical condition, and will notify the Member of the
decision within 24 hours of the request, provided
the Member made the request to PacifiCare (or its
Participating Medical Group) at least 24 hours prior
to the expiration of the previously authorized course
of treatment. If the concurrent care request is not
an Urgent Request, as defined above, PacifiCare will
treat the request as a new request for a Covered
Service under the Health Plan and will follow the time
frame for nonurgent requests, as discussed above.
If you would like a copy of PacifiCare’s policy and
procedure, a description of the processes utilized for
the authorization, modification or denial of health
care services, you may contact the PacifiCare Customer
Service department at 1-800-624-8822.
PacifiCare’s Utilization Management Policy
PacifiCare distributes its policy on financial incentives
to all its Participating Providers, Members and
employees. PacifiCare also requires that Participating
Providers and staff who make utilization decisions
and those who supervise them sign a document
acknowledging receipt of this policy. The policy affirms
that a utilization management decision is based solely
on the appropriateness of a given treatment and
service, as well as the existence of coverage. PacifiCare
does not specifically reward Participating Providers
or other individuals conducting utilization review
for issuing denials of coverage. Financial incentives
for Utilization management decision-makers do not
encourage decisions that result in either the denial or
modification of Medically Necessary Covered Services.
Medical Management Guidelines
The Medical Management Guidelines Committee
(MMGC), consisting of PacifiCare Medical Directors,
provides a forum for the development, review
and adoption of medical management guidelines
to support consistent, appropriate medical care
determinations. The MMGC develops guidelines using
evidenced-based medical literature and publications
related to medical treatment or service. The Medical
Management Guidelines contain practice and
utilization criteria for use when making coverage and
medical care decisions prior to, subsequent to or
concurrent with the provisions of health care services.
Technology Assessment
PacifiCare regularly reviews new procedures, devices,
and drugs to determine whether or not they are safe
and efficacious for our Members. New procedures and
technology that are safe and efficacious are eligible to
become Covered Services. If the technology becomes
a Covered Service, it will be subject to all other terms
and conditions of the plan, including Medical Necessity
and any applicable Member Copayments, or other
payment contributions.
In determining whether to cover a service, PacifiCare
uses proprietary technology guidelines to review
new devices, procedures and drugs, including those
related to behavioral health. When clinical necessity
requires a rapid determination of the safety and
efficacy of a new technology or new application of
an existing technology for an individual Member, a
PacifiCare Medical Director makes a Medical Necessity
determination based on individual Member medical
documentation, review of published scientific evidence
and, when appropriate, seeks relevant specialty or
professional opinion from an individual who has
expertise in the technology.
Utilization Criteria
When a Provider or Member requests Preauthorization
of a procedure/service requiring Preauthorization, an
appropriately qualified licensed health professional
reviews the request. The qualified licensed health