Policies 

Policy:

Serra Community Medical Clinic (SCMC) recognizes that patients and providers may find aspects of the utilization management process complex and burdensome. To assist in minimizing the complexity and restrictive aspect of the utilization process, SCMC has developed procedures to expedite the referral process. When referring a member for Specialty Services the personal physician must follow SCMC’s referral guidelines and should also do the following:

1. Note the referral in the patient medical record
2. Forward copies of medical record/test results to Specialist(s)
3. Coordinate with attending physician when Specialist Consultant and Services are needed during inpatient stays

In-House Referrals:

Specialist are provided at SCMC include but not limited to:

1. Cardiology
2. Chiropractic
3. Family Practice
4. Gastroenterology
5. General Surgery
6. Internal Medicine
7. Mental Health
8. Neurology
9. Nutritionist
10. OB/GYN
11. Ophthalmology
12. Optometry
13. Orthopedics
14. Pain Management
15. Patient Education
16. Pediatrics
17. Physical Therapy
18. Podiatry
19. Urology
20. Stress Test

Referrals to the above in-house specialist require completion of a Referral for Service form. (See policies Open Access to OB/GYN care and Direct Referral Process). Referral and Consultation between Primary Care and Specialist Physician is noted in EMR on the PCP progress note.

"Specialist note reviewed" Yes or N/A will be checked as appropriate. Some SCMC in-house physicians are experienced in handling other services. Prior to a referral being made to an outside specialty, the provider must refer the patient to an appropriate in-house specialist.

Circumstances in which a direct referral would be retrospectively denied include: the member is or will be ineligible at the time of the service or does not have specific benefits for the performed services.

Non-Emergency Services Requiring Prior Authorization:

1. Allergy
2. Audiology
3. Cardiology
4. Chiropractic
5. Dermatology
6. Endocrinology
7. Gastroenterology
8. Nephrology
9. Neurology
10. Neurosurgery
11. Oncology/Hematology
12. Ophthalmology
13. Orthopedics
14. Otolaryngology
15. Pain Management
16. Physical Therapy
17. Podiatry
18. Radiology
19. Rheumatology
20. Urology
21. Diagnostic Procedures
22. DME
23. Home Health
24. Surgery

Non-Emergency Services (In house referrals) that are Auto-Approved:

1. Cardiology
2. Ultrasounds
3. Podiatry
4. Neurology
5. Pain management
6. Treadmill
7. 2 D-Echo
8. Mammogram
9. Bone Density
10. Carotid Artery
11. Doppler
12. Office Procedures
13. Office supplies (crutches, surgical shoes, etc.)
14. EMG/NCS
15. EEG
16. Holter Monitor
17. Visual Field
18. OCT

Self-Referral Services:

An authorization for an initial visit is not required for those patients who self-refer to a provider for the below services:

1. Family Planning
2. Communicable disease. STI
3. OB/GYN and Pre-Natal care within network (See policy Open Access to OB/GYN care)
4. HIV testing and counseling
5. Immunization from local department
6. Abortion (TAB)
7. Preventative Services
8. Sensitive Services
9. Emergency Services
10. Outpatient Mental Health counseling and treatment
11. Drug & Alcohol abuse
12. Services related to sexual assault
13. Out-of-area renal dialysis services
14. Urgent Care sought outside of the service area
15. Urgent Care under unusual or extraordinary circumstances provided in the service area when the contracted medical provider is unavailable or inaccessible.
16. Tobacco Cessation-APL 16-014
17. Services identified in the most current version of the L.A. Care Cal Medi-connect “Direct Referral List” (Auto-Auth)

Outside Referrals:

This applies to Contracted and Non-Contracted providers (See policy for “Referral for Member to Non- Contracted Provider”)

The following list is a sample of outside referrals, which are included but not limited to:

1. Specialist
2. Diagnostic Testing
3. Chemotherapy
4. Radiation Therapy
5. Dialysis
6. DME
7. Surgery
8. Ambulatory Surgical Center
9. Drugs and Medication
10. Ambulance Services
11. Anesthesia
12. Home Health
13. Prosthetics & Orthotics
14. Skilled Nursing
15. Genetic Testing/Amniocentesis
16. Admissions/Sub Acute/Acute Rehab
17. Allergy
18. Hospice
19. Occupational Therapy
20. Chiropractor

When SCMC receives a request, SCMC documents the date the referral was received and the date of the decision in UM file. SCMC has a accepts referrals after normal business hours and on holidays by fax or via internal system (Patient Chart Manager).

If a patient requires referral for services, the following procedures are used for Urgent and non-emergency referrals.

1. Urgent Referrals: within 72 hours from receipt of all necessary information to make the determination.
1. The provider notifies the utilization management department or calls the medical director or on-call physician that the patient is being sent for emergency services.
2. The provider or designee must ensure that the required paperwork is completed.
2. Non-Emergency Referrals: within 5 working days from receipt of all necessary information to make the determination
1. The provider or designee completes a referral for service form.
2. The form and the medical record/pertinent information are forwarded to the utilization management department.
3. Eligibility and benefits are checked, and the referral and accompanying data is forwarded to the UM Nurse for review.
4. If UM Nurse feels criteria is not met, then UM Nurse will forward to medical director for further review.

Approved:

1. An authorization number is issued and the referral for service form and an authorization for service form are returned to the requesting provider.
2. The requesting provider or designee will schedule an appointment for the patient with the outside specialist.
3. The requesting provider or designee will also request a written report from the outside specialist.
4. The requesting provider or designee should schedule the patient for a follow-up appointment at SCMC within a reasonable time to discuss results/recommendations made by the outside specialist.

Timeliness of UM Decision Making:

• For urgent concurrent review (decisions), SCMC makes decisions and gives electronic or written notification of the decision to practitioners and members within 24 hours of the request. Notification must be oral, unless the practitioner or member requests written notification.
• For urgent preservice decisions, SCMC makes decisions and gives electronic or written notification of the decision to practitioners and members within 24 hours of the request. Notification must be oral, unless the practitioner or member requests written notification.
• For nonurgent preservice decisions, SCMC makes decisions and gives initial notification to the practitioner within 24 hours of the decision. Member notification is within 2 business days of the decision for approvals. Written/Electronic notification of a denial to the practitioner and member is done within 2 business days of making the decision
• For nonurgent post service decisions, SCMC makes decisions and gives electronic or written notification of the decision to practitioners and members within 30 calendar days of the request.

SCMC may extend an additional 14 calendar days to make a determination. SCMC will send member a written notice that will include the reason for the delay and inform the member of the right to file an expedited grievance if he or she disagrees with the decision to grant an extension.

If SCMC decides not to expedite a determination, it will automatically transfer the request to the standard timeframe, provide oral notice to the member of the decision not to expedite within 27 hours of receipt of the expedited request and provide written notice within 3 calendar days of the oral notice. The notice must explain that the request will be processed using the standard 14 day timeframe and inform the member of the right to file an expedited grievance if they disagree with the decision not to expedite, inform the member of the right to resubmit a request for expedited determination with any physician support and provide instructions about the grievance process and its time frames.

If SCMC first notifies the member of its adverse expedited determination orally, it must be done so within 24 hours after receiving the request and it must mail written confirmation to the member within three calendar days of the oral notification.

Documentation of oral notification must include date/time of notice. Electronic or written notification must be provided no later than 3 calendar days after the oral notification.

If SCMC first notifies the member of its approval of an expedited request orally, the notification must include date and time of notification. If date and time of oral notification is not documented, enrollee written notification must be mailed within 72 hours after receipt of request (written notification date provided is when notification leaves the delegated entity organization).

If the member or member’s authorized representative does not follow SCMC’s reasonable filing procedures for requesting preservice or urgent concurrent services, SCMC notifies the practitioner or member of the failure and informs them of the procedures to follow when requesting services.

UM Decision Notification to Providers:

Physicians within SCMC are given telephone notification. Written notification is available within SCMC’s EMR for all in house physicians.

Contracted physicians outside of SCMC are given notification of UM decisions by mail and by telephone.

Consultation Communication between Primary Care and Specialist Physician:

EMR is a centralized file for all SCMC patients. Specialist consultations are available in EMR for all SCMC Physicians to review. The PCP will review the specialist progress note(s) and acknowledge on the PCP progress note once reviewed. (i.e. "Specialist note reviewed" Yes or N/A will be checked as appropriate by the PCP.)

Denials:

When a referral request is denied the provider is notified the same day, member is notified in writing, letter is sent the same day, health plan is notified in writing on the same day.

It is the responsibility of the requesting provider to discuss directly with patient an alternative treatment plan. If requesting provider wishes to discuss referral request with Sub-Committee member or Medical Director, s/he may do so by phone or in person. (Refer to attached list). Member is provided with a list to discuss determination with Sub-Committee member, as per NCQA standards.

Denials may occur for various reason(s):

1. Non-covered benefit or limitation, cosmetic surgery
2. Not recommended treatment for symptoms or disease process

1. Recommended second opinion prior to seeking/determining treatment.

The requesting provider or designee is responsible for follow-up on all deferred referrals requests for service include the following:

1. Re-submit a referral for service with documentation to support the request
2. Schedule the patient and perform the recommended alternative treatment.
3. Refer patient to appropriate specialty for second opinion.

Obtaining Clinical Information:

1. SCMC collects relevant clinical information to conduct a medical review of the requested services.
1. SCMC attempts to gather clinical information at least 3 times.
2. Initial attempts for standard pre-service are within 2 calendar days of receipt.
3. Initial attempt for expedited pre-service are within 24 hours of receipt.
4. SCMC will attempt outreach during business hours of providers.
5. SCMC will attempt to collect clinical information via fax, telephone, e-mail, or mail with certified return receipt.

Review Guidelines:

1. A physician advisor may not review case in which there is active involvement by physician advisor, or professional partner in providing medical care.
2. Only one person is needed to approve an admission (i.e. physician advisor or Medical Director). Case Manager may approve admission or continued stay when it meets established criteria.
3. There must be at least two (2) physicians (physician advisor and Medical Director) in agreement to make a non-medical necessity determination.
4. A physician advisor is available to meet or speak in person or via telephone to Utilization Management 24 hours a day for urgent/emergent request.
5. The requesting provider is consulted when appropriate; the physician advisor must make every attempt to contact and/or meet with the referring physician within 24 hours when further member information is required. If the physician advisor is unable to contact the referring physician, the case will be referred to the Medical Director for a medical necessity determination.
6. The physician advisor and Medical Director must make all medical necessity determination(s) based on medical information only. There are no incentives for inappropriate reviews/decisions.

Request for information:

(CMS) Outreach for information to support Coverage Decisions

When requesting additional information, a minimum of three attempts during normal business hours. Request for information will be documented and maintained in the case file including a specific description of the required information. The name, phone number, fax number, e-mail and/or mailing address, as applicable for the point of contact. The date and time of each request, documented by date and time stamps on copies of a written request, call record, fax transmission, e-mail and/or overnight mail with certified return receipt. Call records will include specific information about who was contacted, what was discussed/requested, and what information was obtained by the plan.

Relevant Information:

UM decisions directly related to request by member or by their authorized representatives for authorization or payment for health care services, whether requests are based on benefits or non-medical necessity, and whether they are approval or denials. Clinical information may include:

• Office and hospital records
• A history of the presenting symptoms
• Physical exam results
• Diagnostic testing results
• Treatment plan and progress notes
• Patient psychosocial history
• Information on consultations with the treating practitioner
• Evaluations from other health care practitioners and providers
• Operative and pathological reports
• Rehabilitation evaluations
• A printed copy of criteria related to the requesting
• Information regarding benefits for services or procedures
• Information regarding the local deliver system
• Patient characteristics and information

Rescinding or Modifying an Authorization– AB 1455 requirement – Prohibit the UM organization from rescinding or modifying an authorization once services have been rendered by the provider.

No authorization shall be rescinded or modified after the provider renders the health care service in good faith for any reason, including, but not limited to, subsequent rescissions, cancellations or modification of the member’s contract or when the delegate did not make an accurate determination of the member’s eligibility

AB 1324 Serra Community Medical Clinic will identify and manage open authorizations and ensure that the provider’s claims are paid appropriately for services provided in good faith when an authorization has been given, but the member is later to be determined to have been ineligible at the time of service.

APL 21-001 Title 42 CFR section 431.211-213-214

For terminations, suspensions, or reductions of previously authorized services, MCPs must notify members at least ten days prior to the date of the action pursuant to Title 42 CFR section 431.211 to ensure there is adequate time for members to timely file for Aid Paid Pending, with the exception of circumstances permitted under Title 42 CFR sections 431.213 and 431.214.

UM Reporting:

1. SCMC monitors and submits report for timeliness of:
1. Nonbehavioral UM Decision making.
• All UM decisions whether requests are based on benefits or on medical necessity, and whether they are approvals or denials.
2. Notification of Nonbehavioral UM Decision
• All UM decisions whether requests are based on benefits or on medical necessity, and whether they are approvals or denials.
3. Behavioral UM Decision making
• All UM Decision whether requests are based on benefits or on medical necessity, and whether they are approvals or denials.
4. Notification of Behavioral UM Decision
• All UM decisions whether requests are based on benefits or on medical necessity, and whether they are approvals or denials.
5. Notification of Pharmacy UM Decisions
6. Pharmacy UM Decisions
2. All SCMC reports calculate the percentage of decisions that adhere to NCQA time frame requirements, using at least six months of data.
1. At a minimum, rates of adherence are calculated for each category of request (urgent concurrent, urgent preservice, nonurgent preservice, and post service) for each factor.

Internal audits: Referral Accuracy and Completeness

1. Random monthly request will be reviewed to ensure referrals are processed correctly and all required documents are filed in PCM.
• Authorization / Denial
• Referral request
• Notes /supporting documents
• Eligibility/ preferred language
• Letter Member/ Provider
• Inserts
• Criteria
• Flesch Kincaid
• Notification Member/ Provider
• Timeliness Met

Summary of findings will be logged in the “Monthly Referral Request Audit Log”. A log

Will be kept for each health plan. The audit will be completed within 15 days after the closing of the previous month.

Purpose and Scope

The Utilization Management (UM) Program is designed to monitor, evaluate and mange health care services to assure that quality patient care is provided in the most effective and cost-efficient manner to all members and members group. Whether delegated or non-delegated, this program will ensure that:

• Services are medically necessary, relevant and delivered at appropriate levels of care.
• Guidelines, standards and criteria set by government and other regulatory agencies are adhered to appropriately.
• Cost of services are evaluated and monitored to determine appropriateness and cost benefit factors.
• Appropriateness of treatment frequency is determined so that services are not over or underutilized and to prevent duplication of diagnostic tests and Services.
• Appropriateness care is offered in a timely and quality manner utilizing standard criteria and informational resources to determine appropriateness of services to be delivered. (Apollo’s Medical Review Criteria)
• The UM Program is reviewed, updated, and revised annually by the UM Committee with final approval by the Board of Directors.
• New and existing technology will be evaluated according to policy and procedure and will be reviewed by health plan 24 hours prior to determination regarding approval.
• Coordinate UM activities with other performance monitoring and management activities, including quality management, risk management, provider accessibility and availability, patient and provider satisfaction, outcome of contractual and internal audits and resolution and monitoring of member complaints and grievances.

Structure

• UM Staff members assigned activities.
• UM Staff who have the authority to deny coverage.
• Involvement of a designated physician and a designated behavioral healthcare practitioner.
• There is a process for evaluation, improving and revising the UM Program, and the staff responsible for each step.
• The UM program’s role in the Quality Management / Quality Improvement (QM/QI) Program including how Serra Community Medical Clinic (SCMC) collects UM information and uses it for QM/QI Activities.

Goals and Objectives

• Provide access to the most appropriate and cost-efficient healthcare services.
• Ensure authorized services are covered under the member’s health plan benefits.
• Develop systems to evaluate and determine which services are consistent with accepted standards of medical practice.
• Perform Peer Review in conjunction with the QM/QI Program when necessary.
• Coordinate through and timely investigations and responses to member and provider grievances that are associated with utilization issues.
• Initiate necessary procedural revisions to prevent problematic utilization issues from recurring.
• Ensure that services that are delivered are medically necessary and are consistent with the patient’s diagnosis and level of care provided.
• For Medicare services: reasonable and necessary for the diagnosis or treatment of illness or injury to improve the functioning of a malformed body member, or otherwise medically necessary under 42 CFR 1395.
• For Medi-Cal services: reasonable and necessary to protect life, prevent significant illness, or significant disability, or to alleviate severe pain through the diagnosis or treatment of disease, illness, or injury as under Title 22 California Code of Regulations (CCR) Section 51303.
• For Commercial services: reasonable and necessary for the diagnosis or treatment of illness or injury to improve the functioning of a malformed body member, or otherwise medically necessary
• Facilitate communication and develop positive relationships between members, physicians and health plans by providing education related to appropriate utilization.
• Evaluate and monitor healthcare services provided by IPA contracted providers by tracking and trending data.
• Monitor, evaluate and improve continuity and coordination of care.
• Identify over and underutilization of services.
• Identify “high risk” members and ensure that appropriate care is delivered by accessing the most efficient resources.
• Reduce overall healthcare expenditures by developing and implementing effective health promotion programs.
• Use UM data in the process of re- credentialing providers.
• Continuously monitor, evaluate and improve the UM Program and integrate the UM Program appropriately into the QM/QI process.
• Ensure cohesive IPA interdepartmental process with the UM process.
• Identify potential quality of care/service issues.

Authority

The Board of Directors has accountability for the UM Program. The Board has delegated the authority for the coordination and management of the UM Program to the UM Committee.

Senior Level Physician

The senior-level physician, who is the medical director, is involved in UM activities include implementation, supervision, oversight and evaluation of the UM Program. The medical director is responsible for evaluating, approving and revising the UM Program. The medical director is the only member of the UM Staff with authority to deny coverage. The senior-level physician’s responsibilities

include, but are not limited to setting UM policies, supervising program operations, reviewing UM cases, participating on the UM Committee, and evaluating the overall effectiveness of the UM process. The medical director must hold an unrestricted license to practice medicine in the State of California issued pursuant to Section 2050 of the Business and Professional Code or pursuant to Osteopathic Act. H&SC 1367. 01 (c)

Committees

The UM Committee meets quarterly for a minimum of 4 times per year. Meeting time and location is circulated to committee members quarterly. The committee may meet more frequently if deemed necessary by the Chairperson/ Chief Medical Officer, Administrator or Board of Trustees. The Medical Director or designee is the Chairperson of the Committee.

The Administrator and Chief Medical Officer appoint committee members. The Committee member will serve on the committee for one (1) year. Members are chosen from various specialties and actively participate. Members include administrative staff involved in quality care and provider panel. Criteria for membership urges member to maintain meeting attendance and involvement in discussion of agenda items, establishing practice guidelines, selection of monitoring indicators and studies, analyzing results and assisting in follow-up and problem resolution as requested by the Committee. All medical staff committee members have voting rights. At least 3 physicians must be present to make a quorum. Only practitioners (physicians) have the right to vote on medical issues.

The UM Committee has responsibility for the oversight and direction of all UM functions. Its purpose is to identify problems based on analysis of trends, statistics, provider referral patterns, claims, utilization screens, data, reports, inpatient and outpatient medical records, eligibility reports and to address care issues. It educates committee members in the healthcare delivery system and shares information and expectation for improvement. The committee prioritizes problems that most directly affect patient care and reviews the recommendations of medical and ancillary staff.

Referral to the appropriate department of specialty will be made for plans of action. Incentive and/or bonuses will not be used at any time to influence decisions made by the UM Committee members and/or Medical Director.

The Committee consists of:

• Medical Chairperson (appointed by the Board of Directors),
• Senior Manager designated by the Board of Directors (usually the Administrator),
• Quality Improvement Manager,
• UM Director,
• Physicians representing at least three medicines (Pediatrics, OB/GYN, Internal Medicine) or surgery subspecialties, the criteria for subspecialty physician membership is as follows:
• Board Certification in an area of specialty
• Association with SCMC for one year or more.
• Have necessary credentials and extended education units in specialty
• A designated Behavioral Health Care Practitioner has substantial involvement in the implementation of behavioral health aspect of the UM program

Non-Member physicians may be invited to attend the meetings to obtain expert consultative or specialty opinions.

SCMC gives practitioners with clinical expertise in the area being reviewed, the opportunity to advise or comment on development or adoption of UM criteria, and on instructions for applying criteria.

SCMC solicits opinions about the UM Criteria through the practitioner’s participation on the UM Committee.

Support staff may be invited on an as needed basis may include representatives from the Credentialing Committee, Health Promotion Education Manager, Management Staff, Nursing or Utilization Management Staff.

Health plan medical directors and /or health plan representatives may attend meetings with prior arrangements. All guests must sign a Confidentiality/Affirmative Statement.

In the event of the resignation or departure of a committee member, the Board of Directors will review applicants that meet the above criteria.

The UM Committee was formed to assist in the development of primary care physician education sessions regarding specialty care, assisting in obtaining provider feedback regarding the UM Program and UM issues, analyze provider utilization, developing or revising utilization guidelines and delineating the various provider roles. Monitoring of referrals to non-contracted providers and facilities, recommending new specialties to the membership/credentialing committee, developing clinical pathways to be used as a reference tool by providers, assist in the process for evaluating new and existing technologies.

The Quality Improvement Manager has the responsibility for conducting ongoing studies and data collection for quality and appropriateness of medical treatment. Data and finding from studies will be shared between the UM and QM committees and communicated quarterly. Trends by physicians, ancillary services or enrollees will be analyzed and corrective action taken and documented.

Minutes of both committees are documented and maintained in the QI Department. The proceedings of the committees and their derivative documents and minutes are confidential and protected from discoverability under 1157 of the California Evidence Code. Members of the Committee(s) have a duty to preserve this confidentiality. To ensure this, patient names will not be used. The UM Committee must abide by the Confidentiality of Medical Information Act in maintaining confidentiality statement annually and by visitors prior to attending meeting.

Program Administration

Daily administration and management of the program is delegated to the Medical Director who is assisted by the UM Director. The Medical Director has substantial involvement in the development of and implementation of the UM Program and participants in multidisciplinary problem solving.

Responsibility of this position is delineated in the Medical Director position description.

Conflict of Interest

A physician may not participate in the review of any case that s/he has been or anticipates being

professionally involved. Physicians having a direct financial interest in case(s) being reviewed may not participate in review activities.

Credentialing

Any new provider will be credentialed prior to the first appointment. All providers will be credentialed every three (3) years. Prior to re-credentialing, Peer Review items, UM findings and grievances will be considered at the time of reappointment. The Medical Director reviews all provider applications.

Credentialing is a function of the UM Committee. The Medical Directors and physician reviewers or consultants who make UM decisions for pre-service, concurrent, post-service and retrospective claims must be credentialed by the SCMC. Section 42 CFR € 422.204 (b)(2): Manual Chapter 6 – Section 60.3

The policies apply to SCMC and its satellites. The policies and procedures are designed to support and enhance the efforts of the prospective hospitalization review.

Standardized Utilization Management Criteria

Standard UM Criteria is the UM manual for review by physicians, practitioner, and specialty consultants. A written copy is available to providers and patients upon requests to the Quality Improvement Department.

Prospective Review

The attending physician will notify the physician advisor to request approval for all elective admissions.

Reviews will include:

• Necessity of admission.
• Completion of pre-admit work up.
• Assignment of specific number of days.
• Written authorization.
• A Copy of the approval to utilization management and admitting departments (admissions are logged or monitored).

Assigned Responsibilities Medical Director

Responsibility: Board Certified Physician

Licensed Board-Certified physicians will make denial service determinations. The signature of the Medical Director or a reviewing member of the UM-Sub Committee is required on the denied referral request authorization form. The Medical Director is the head of the UM Department; all denials are reviewed only by the Medical Director.

Behavioral Health: Licensed physicians must oversee UM decisions to ensure consistent medical necessity decision making. Licensed doctoral level clinical psychologist may oversee behavioral health UM decisions. These individuals are not required to have day to day involvement in UM activities but there must be evidence of high level of oversight to BH staff, review of BH UM decisions to ensure consistency and involvement in complex cases. For doctoral level clinical psychologist, such authority must be within the scope of their license to practice.

Case Management

Responsibility: Nurse Case Manager

The Case Manager is to ensure that medically necessary care is delivered in the most cost – efficient setting for members who require extensive or ongoing services. The program will be focused on the delivery of the cost – effective, appropriate healthcare services for members with complex and chronic care needs.

Once medical necessity is determined for post discharge service, benefits and eligibility are verified. An authorization number is assigned for the service requested and the number recorded on the concurrent review sheet and given to the vendor with approved dates of the services. The case manager initiates contact to evaluate the progress of the patient and the response to treatment. If further services are requested, the case manager will obtain all sustaining consultations, progress reports and summaries prior to approval of additional services.

Discharge Planning

Responsibility: UM Coordinator and Inpatient Nurse

A case manager initiates discharge planning within the first 24 hours of admission. A needs assessment is completed on every patient. Patient interviews are conducted with patients to determine what services will be needed after discharge (home care, nursing home care, rehabilitative care, out-patient medical treatment). Discharge planning arrangements are documented on the concurrent review sheet and noted in the patient’s medical record by the case manager.

Clerical, Receptionist, non-licensed Staff Responsibility: Coordinators and Clerks

Non-Licensed staff are responsible for the processing of referrals, follow-up calls, answering phones, and checking eligibility. UM Coordinator may assist the nurse for delegated coordinating tasks. Staff who make medical UM decisions are supervised by a licensed practitioner with appropriate clinical experience (e.g. Physician, RN, NP, or other appropriately licensed staff).

Staff will make BH UM decisions are supervised by a licensed practitioner with appropriate clinical experience in BH (e.g. psychologist, social worker, registered psychiatric nurse, or other appropriately licensed BH UM staff).

Outpatient Review

Responsibility: UM Nurse Reviewer

The criteria used to determine medical necessity for outpatient services is the Apollo Care Guidelines. A licensed practitioner does a medical review for medical necessity of requested services. Coverage is determined by running eligibility and benefits. The Criteria are annually reviewed and updated. The data and information SCMC use to make determination of coverage are based on patient’s medical records, conversation with appropriate physicians, assessments, evaluations, and other records. This process is the most efficient and least burdensome on the patient, physician, and organization.

Concurrent Review (Inpatient)

Responsibility: UR Inpatient Nurse and Case Manager

The criteria used to determine medical necessity for inpatient services is the Apollo Care Guidelines. The case manager will review and monitor the patient’s stay to verify continued need for stay and medical necessity within 24-hours/1 working day. If additional days are medically necessary, it must be documented on the review sheet and patient record and a new review date assigned. If medical necessity is not found for continued stay, the discharge date will be documented compared to Apollo’s Medical Review Criteria. The case manager will contact the physician for discharge. Standard maximum time frame established for resolution of the inpatient concurrent review request is one working day. The Criteria are annually reviewed and updated. Updating of the criteria and the procedure for applying.

Care shall not be discontinued until the enrollee’s treating provider has been notified of the plan’s decision, and the treating provider that is appropriate for the medical needs of that patient has agreed upon a care plan.

Retrospective Review

Responsibility: Outpatient UM Nurse Reviewer

Retrospective Review is a process in which authorizations have not been processed prior to the services having been rendered to members. UM works in conjunction with Business Office that retrospective Review is done in a timely manner. Medical records and claim(s) are submitted to UM Committee for retrospective review for medical justification using Apollo’s Medical Review Criteria. The medical record will be reviewed to determine appropriateness of length of stay, ancillary charges, late charges, medication usage (medication given to take home), duplication charges and total charges.

Examples of services that will be reviewed are as follows:

• Unauthorized referrals in and out of network
• Hospitalizations
• Outside Hospitalizations
• Emergency Room Visits
• DME & Ostomy supplies
• Skilled Nursing Facility
• Home Health Services

Appeals

SCMC has established procedures for registering and responding to appeals.

Inquires of an urgent medical nature, that meet criteria for the expedited initial determination, will be reviewed and resolved within 72 hours of receipt.

The following is a list of the criteria for expedited review process (this list is not all-inclusive):

• All Rehabilitation Hospitals, Skilled Nursing, Home Health Care request.
• All Physical Therapy request within 4 months of a CVA, head injury or surgery, or other acute trauma.
• All request for continued Physical Therapy within 4 months of a major joint (e.g., hip, total knee) surgery.

• Request for medication, chemotherapy, or proposed surgical treatment of a known malignancy (Cancer).
• Request for a proposed AIDS therapy in an AIDS patient.
• Any request for a proposed “experimental” treatment in a terminal patient (consult the CA State Law to define “terminal”).
• Any request by a physician for urgent determination review.

Any call where there is refusal by the provider to proceed with a scheduled service because the contracting provider has failed to give authorization on a service that has been scheduled but no authorization issued on which to proceed). Note A request for a referral must already have been submitted.

• Any other life-threatening pre-service issue.

Reason for Non-Behavioral Health Denial

SCMC shall provide written notification that contains the following:

• The specific reason(s) for the denial, in easily understandable language.
• A reference to the benefit provision, guideline, protocol or other similar criterion on which the denial is based.
• Notification that the patient can obtain a copy of the actual benefit provision, guideline, protocol or other similar criterion on which the denial was based, upon request.

Non-Behavioral Health Notification of Appeal rights and appeal process the notification will contain the following:

• Description of appeal rights, including the right to submit written comments, documents or other information relevant to the appeal.
• Explanation of the appeal process, including the right to member representation and timeframes for deciding appeals.
• If a denial is an urgent pre-service or urgent concurrent denial, a description of the expedited appeals process.

Reasons for Behavioral Health Denial

SCMC shall provide written notification of the denial that contain the following:

• The specific reason(s) for the denial, in easily understandable language.
• A reference to the benefit provision, guideline, protocol or similar criterion on which the denial decision is based.
• Notification that the patient can obtain a copy of the actual benefit provision, guideline, protocol or similar criterion on which the denial was based, upon request.

*Seniority Plus Only

Behavioral Health notification of Appeal Rights and Appeal Process

SCMC shall provide written notification that contain the following:

• Description of appeal rights, including the right to submit written comments, documents or other information relevant to the appeal.
• Explanation of the appeal process, including the right to patient representation and timeframe for deciding appeals.
• If a denial is an urgent pre-service or urgent concurrent denial, a description of the expedited

appeal process.

Documentation will be maintained on file for authorizations retrospectively given, within 30 days of receiving the non-authorized claim or notification of service.

Emergency Room Services

Emergency Room service authorizations requested during the hours of 0800-1700 Monday through Friday will be done concurrently by On Call PCP or Pediatrician. For services on weekends or holidays the On-Call Physicians will be notified. In regard to unauthorized services rendered to member, the retrospective review process will be followed.

NCQA definition of “prudent layperson” – a person who is without medical training and who draws on his or her practical experience when making a decision regarding whether emergency medical treatment is needed. A prudent layperson is considered to have acted “reasonably” if other similarly situated laypersons would have believed, on the basis of observation of the medical symptoms at hand, that emergency medical treatment was necessary.

Outside and Clinical Referrals

The provider will submit the referral to the Quality Improvement Department. (Refer to policy and procedures on Referrals, Specialty Referral & Tracking and HMO Protcols policy.) When a contracted practitioner is not available, an appropriate provider is contacted, and a contract negotiated to provide the needed service(s).

Preexisting conditions

If a member has creditable coverage and the organization has a policy to deny preexisting care or services. Coverage and benefits cannot be denied or limited because of a preexisting health condition such as asthma, diabetes, cancer or pregnancy.

Home Health Care

The attending physician must order home health care. The agency must be an approved provider by the health plan or group. The UM Committee must review all home health care. Continued care must be approved on a monthly basis.

The appropriate health plan will be notified of the following cases that include but are not necessarily limited to:

• Renal Failure
• Catastrophic cases
• Cases with LOS > 10 days
• AIDS
• Hospice

Second Opinion

 

Medi-Cal members are allowed second opinion at no cost.

The second medical opinion must be rendered by a qualified health care professional and other licensed health care providers as well as, PCP or specialist acting within the scope of practice and who possess

clinical background including training and expertise, related to the illness or condition. The second opinion may be provided by a professional within the Health Plan’s or Serra’s network of providers for Covered CA members. If there is not a qualified health care professional in the network, the health plan or Serra will arrange for one.

Patient-initiated second opinions that relate to the medical need for surgery or for major nonsurgical diagnostic and therapeutic procedures (e.g., invasive diagnostic techniques such as cardiac catheterization and gastroscopy) are covered under Medicare.

If the recommendation of the first and second physician differs regarding the need for surgery (or other major procedure), additional medical (third) opinions concerning the medical condition of the member is covered and may be authorized by the Health Plan or SCMC

Second and third opinions are covered even though the surgery or other procedure, if performed, is determined not covered.

Volume indicators are developed annually and reviewed quarterly for outpatient surgery and diagnostic procedures and out-of-plan second opinions and IPA referrals to include number of:

• Outpatient
• Admissions post outpatient surgery
• Cancelled Surgeries
• Endoscopic Procedures
• Cardiac Cath Procedures
• Outpatient blood administration procedures

Risk Services

All services requested for out-of-area (greater than 30 miles from assigned hospital) will be directed to the member’s plan for approval. Out-of-network services that are only covered in clinically appropriate situations.

Transfers

A patient is transferred to a participating hospital if medically stable. The attending physician or designee will communicate to the receiving PCP or designee of the patient’s condition and other pertinent information. All pertinent information regarding the patient and the transfer is to be forwarded to admission/ER.

Behavioral Health

Referrals for Behavioral Health Care and services will be processed according to medical necessity, the member’s benefit plan and within the decision time standards as per NCQA. The UM staff at SCMC is aware that many of the Managed Care Health Plans have carved out behavioral health services to various behavioral health providers and will refer request to the appropriate health plan for behavioral health treatment to include Applied Behavioral analysis for members with autism Spectrum Disorder (ASD).

The designated behavioral healthcare physician is involved in implementing and evaluating the behavioral healthcare aspects of the UM Program. The responsibilities of the designated behavioral healthcare practitioner may include but are not limited to setting UM behavioral healthcare policies,

reviewing UM behavioral healthcare cases, and participating on the UM Committee.

The Behavioral Health Care Practitioner must be a physician or have a clinical PhD or PsyD, and may be a medical director, clinical director, participating practitioner from the SCMC or behavioral health care delegate.

See Behavioral Health Policy for details.

Dental Services

Dental surgical procedure that occur within or adjacent to the oral cavity or sinus are covered under the members medical benefit.

Inter-Reviewer Reliability

The UM Sub-Committee chairperson, physicians, UM Director, Case Manager and HMO Coordinators, conducts periodic evaluations of the utilization review process. The results are noted in the UM Committee meeting minutes. The purpose of the evaluations is to measure comprehension of the clinical practice guidelines to ensure accurate and consistent application of the criteria among reviews and review determination of the UM staff/committee to ascertain consistent application of criteria for all providers. (Refer to policy Inter Reviewer Reliability).

Timeliness of UM Decision Making

SCMC adheres to the ICE UM Timeliness standards for CA Commercial HMO, CMS and Medi-cal. Health and Safety Code 1367.01 will be enforced 5 working days from the receipt of the request.

• Urgent Concurrent Review: SCMC makes decisions within 24 hours of receipt of the request. SCMC will give written or electronic notification to the practitioner or member of the decision within 24 hours of receiving request for services.
• Urgent Preservice decisions: SCMC makes decisions within 72 hours of receipt of the request. SCMC will give written or electronic notification to the practitioner or member of the decision within 24 hours of receiving the request for services.
• Nonurgent preservice decisions: SCMC makes decisions within 5 business days of receipt of the request. SCMC will give written or electronic notification to the practitioner or member of decision within 2 business days of receiving the request for services. (Medicare: 14 days of receipt of the request, if extension requested/needed; may extend up to 14 calendar days, not to exceed 28 calendar days).
• Post service decisions: SCMC makes decisions within 30 calendar days of receipt of the request. SCMC will give written or electron notification of decision.

The decision time starts from the date when SCMC receives the request from the member or member’s authorized representative, even if SCMC does not have all the information necessary to make the decision. Notification may be oral, unless the practitioner or member request written notification.

Reporting

 

Reports must be consistently submitted to the health plan on a timely basis and include identification and reporting mechanisms of over/under utilization, including action plans implemented as necessary to improve detected over/under utilization patterns. Monthly and Quarterly reporting shall be submitted as required by the Health Plans according to the current reporting Matrix.

UM Timeliness Reports

SCMC monitors and submits a report for timeliness of:

• Non-behavioral UM decision making.
• Notification of non-behavioral UM decisions.
• Behavioral UM decision making.
• Notification for behavioral UM decisions.
• Pharmacy UM decision making.
• Notification of pharmacy UM decision.

This applies to all the UM decisions directly related to requests by members or by their authorized representatives for authorization or payment for health care services, whether requests are based on benefits or on medical necessity, and whether they are approvals or denials.

Urgent Concurrent Request

The request to extend urgent concurrent care was not made prior to 24 hours before the expiration of the prescribed period of time or number of treatments. SCMC may treat the request as urgent preservice and make a decision within 72 hours.

The request to approve additional days for urgent concurrent care is related to care not approved by the organization previously. SCMC documents that it made at least one attempt to obtain the necessary information within 24 hours of the request but was unable to. SCMC has up to 72 hours to make a decision.

Urgent Preservice Request

SCMC may extend the urgent preservice time frame due to lack of information, once, for 48 hours, under the following conditions:

• Within 24 hours of receipt of the urgent preservice request, SCMC asks the member (or the members’ representative) for the specific information necessary to make the decision.
• SCMC gives the member at least 48 hours to provide the information.

The extension period, within which a decision must be made by SCMC, begins:

• On the date when the organization receives the member’s response (even if not all of the information is provided) or
• At the end of the time period given to the member to provide the information, if no response is received from member or the member’s authorized representative.

Non-Urgent Preservice and Post service request

If the request lacks clinical information, SCMC may extend the nonurgent preservice or post service time frame up to 5 calendar days (Medicare: 14 calendar days), under the following conditions:

• SCMC asks the member (or the member’s representative) for the specific information necessary to make the decision within the decision time frame.
• SCMC give the member (or member’s representative) at least 45 calendar days to provide the information.
• The extension period, within which a decision must be made by SCMC begins:

                   o On the date when SCMC receives the member’s response (even if not all of the                

information is provided), or

• At the end of the time period given to the member to supply the information, if no response is received from the member or the member’s authorized representative.

Time frames for timeliness of Pharmacy Prior Authorization Request Commercial: CA Health & Safety Code section 1367.241(CA SB 282; 2015-2016)

• Urgent Concurrent-(exigent) decision and notification within 24 hours of the request.
• Urgent Preservice-(exigent) decision and notification within 24 hours of the request.
• Non-Urgent Pre-service- decision and notification within 72 hours of the receipt of the request.
• Post Service- decision and written notification within 30 days of receipt of request.

Senior:

Initial Coverage Decisions- Timeframes for Adjudicating Part B Drug Requests – Medicare Advantage Organizations (effective January 1, 2020)

Pursuant to CMS-4180-F, there are shorter adjudication timeframes for Part B drug requests than the timeframes that apply to requests for medical items and services. MA organizations must adjudicate requests in accordance with the rules at 42 CFR §§ 422.568, 422.570, 422.572, 422.584, 422.590 and effectuate favorable decisions in accordance with the rules at §§ 422.618 and 422.619.

Part B drug determination timeframes and notice requirements are as follows:

• Must make determination and notify the enrollee (and the physician or prescriber involved, as appropriate).
• Urgent Concurrent-decision and notification within 24 hours of the request.
• Urgent Pre-service-decision and notification within 24 hours of the request.
• Non-Urgent Pre-service- decision and notification within 72 hours of the receipt of the request.
• Post Service- decision and written notification within 30 days of receipt of request.

Medi-Cal:

• Urgent Concurrent-(exigent) decision and notification within 24 hours of the request.
• Urgent Pre-service-(exigent) decision and notification within 24 hours of the request.
• Non-Urgent Pre-service- decision and notification within 5 business days of the receipt of the request, written notification within 2 business days of decision.
• Post Service- decision and written notification within 30 days of receipt of request.

SCMC will utilize the most current required DMHC Prescription Drug and Prior authorization form for all prior authorization prescription requests submitted to the Health Plans. Form will be submitted via secure fax to the health plan.

Prior authorization for pharmaceuticals and pharmaceutical request required prerequisite drug for a step therapy program.

Denial, Deferral and/or Modification of referral requests

A denial, deferral and/or modification of a referral request may occur so that more information can be obtained, or recommendations of alternative care may be made during the authorization process. Other than the member is not eligible, only licensed Board-Certified physicians will make denial service determinations. The signature of the Medical Director or a reviewing member of the UM-Sub

Committee is required on the denied referral request authorization form.

Compensation Plan

SCMC does not have a compensation plan for individuals who provide utilization review services. (Refer to Confidentiality/Affirmative. SCMC distributes this statement affirming that UM decision making is based only on appropriateness of care, service, and existence of coverage. Practitioners and staff sign affirmative statements annually during QI meeting. SCMC does not specifically reward practitioners or other individuals for issuing denials of coverage or service care; financial incentives for UM decision makers do not encourage decisions that result in underutilization. Serra Community Medical Clinic distributes this statement to all staff, including:

• Practitioners
• Providers
• Employees
• Enrollee

Signs are posted (English/Spanish) on every floor. Website and paper copy available upon request. Serra will mail it affirmative statement about incentives to recipients who do not have fax, email or internet access

We affirm that:

• UM decision making is based only on appropriateness of care and service and existence of coverage
• Serra Community Medical Clinic, Inc., does not specifically reward practitioners or other individuals conducting utilization review for issuing denials/deferrals/modification of coverage or service.
• Financial incentives for UM decision – makers do not encourage decisions that result in underutilization.
• SCMC does not use incentives to encourage barriers to care and service.
• Medical Management Program description, policies practitioner contracts must not contain language indicating improper utilization incentive programs. Terms under which a practitioner may be entitled to a bonus or incentive pay cannot influence a practitioner’s decision to withhold, delay, or deny necessary service.
• Practitioners are ensured independence and impartiality in making referral decisions that will not influence:
• Hiring
• Compensation
• Termination
• Promotion
• Any other similar matters

Annual Program Evaluation

The UM Committee for effectiveness and consistency evaluates and updates SCMC’s UM Program annually with program objectives using a standardized format. Program evaluation/revisions are reviewed and approved by the Board of Directors at least annually. The program evaluation is distributed according to contractual agreements. A current copy is available for review in the UM Committee meeting minutes.

In order to assure that all commercial members are treated uniformly, application of the health plan timeliness standards will apply to all commercial members, regardless of ERISA status.

Annually review UM denials against regulatory standards for each year the delegation has been in effect. (Not delegate UM).

SCMC performs random quality assurance tests on systems to ensure that processing and notification of standard and expedited organization determination requests occur within required timeframes.

• SCMC ensures systems clearly indicate the date and time (for expedited and standard requests) of receipt of a SCMC determination or reconsideration requests and identify whether it is a standard or expedited request.
• Reports of pending workload are provided to management on a daily basis.

Annually evaluates delegate performance against regulatory standards for delegated activities. (Not delegated).

CAP (Corrective Action Plan):

The UM Director and Medical Director will implement the corrective action plan (CAP) to the health plan in the designated timeframe. All deficiencies will be address and corrected.

• Upon notification of any deficiencies, will develop a corrective action plan (CAP) using the appropriate format.
• Will respond with corrective action plan (CAP) in the appropriate timeframe.
• Will implement corrective action plan within 30 days. All changes will be taken to the QI committee for approval.
• Corrective action plan (CAP) will be implemented after approved by the committee and all needed follow-up will be done.
• Corrective action plan (CAP) will be show the responsible persons’ name and title.