Care Management > Types of Utilization Reviews
The following are types of reviews that we and our delegates conduct, along with the time frames in which our utilization determinations must be made (once the necessary information is received).
We must make a determination if a prior approval is warranted and notify the member and the provider of the determination by phone and in writing. The determination must be made within three business days of receipt of the necessary information.
In addition to the phone calls made and letters sent, providers will be able to access the status of a prior approval request, and the determination when made, at www.emblemhealth.com after signing in. At this time, for GHI members, the determinations posted to our secure website are limited to those made with respect to elective inpatient stays.
We must make a determination if a concurrent approval is warranted and notify the member and provider by phone and in writing. The determination must be made within one business day of receipt of the necessary information. Hospitals and skilled nursing facilities receive a Concurrent Review Status Report for HIP and CompreHealth EPO members twice daily - in the morning and afternoon, which is posted to www.emblemhealth.com behind sign-in.
In addition to the phone calls made and letters sent, providers will be able to access the status of a case when they sign in to www.emblemhealth.com. Hospitals and skilled nursing facilities receive a Concurrent Review Status Report for HIP and CompreHealth EPO members twice daily - in the morning and afternoon, which is posted to www.emblemhealth.com behind sign-in.
We must make a determination if a retrospective approval is warranted and notify the member and the provider of the determination by phone and in writing. We must make a decision within 30 days of receipt of the necessary information.
The expedited review must be conducted when we determine or provider indicates a delay would seriously jeopardize the member's life, health or ability to attain, maintain, or regain maximum functions. Members have the right to request an expedited review, but we may provide an adverse determination and notice will be given under standard time frames.
Reconsiderations are available to providers for adverse determinations whenever possible. Physicians who were not involved in the initial determination will review appeals. Written notice of the determination will be provided to the patient, to the attending provider and to the facility, if applicable. Notification of adverse determinations will include the clinical rationale for the determination and all applicable grievance and appeal rights. Provider appeal rights are further described in the Dispute Resolution chapters of this manual.
Expedited Review of Inpatient Cases
If the review does not meet medical necessity criteria, the concurrent review nurse reviews the case with an EmblemHealth medical director who will render a decision. Whether the stay is approved or denied as not medically necessary, the concurrent review nurse notifies all applicable parties (i.e., the attending physician, the facility and the member) by telephone and/or fax within one working day of making the decision, and gives members and practitioners written or electronic confirmation within 24 hours if the request is received 24 hours prior to the end of the current approved period. If the request is received less than 24 hours before the end of the current approved period, the determination and notification will be made within one business day of receipt of all necessary information but no more than 72 hours from receipt of request.
Glossary terms found on this page:
A determination by EmblemHealth or its agents that an admission, extension of stay or other health care service has been reviewed and, based on the information provided, is not medically necessary.
Oral or written request from a member or their designee for EmblemHealth to review or reconsider a decision made by the plan.
The physician primarily responsible for the care of a patient during hospitalization. The physician is licensed, board-certified or board-eligible and qualified to practice in the area appropriate to treat the member's life-threatening or disabling condition or disease. The attending physician must be a network provider with EmblemHealth or one to which EmblemHealth has referred the member.
A statement that provides additional clarification of the clinical basis for a noncertification determination. The clinical rationale should relate the noncertification determination to the patient's condition or treatment plan, and should supply a sufficient basis for a decision to pursue an appeal.
An entity contracted with EmblemHealth to perform various services including utilization review, credentialing and claims processing. Also called managing entities and carve outs.
A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.
A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.
A request to change an adverse determination that was based on administrative policies, procedures or guidelines.
An institution which provides inpatient services under the supervision of a physician, and meets the following requirements:
- Provides diagnostic and therapeutic services for medical diagnosis, treatment and care of injured and sick persons and has, as a minimum, laboratory and radiology services and organized departments of medicine and surgery
- Has an organized medical staff which may include, in addition to doctors of medicine, doctors of osteopathy and dentistry
- Has bylaws, rules and regulations pertaining to standards of medical care and service rendered by its medical staff
- Maintains medical records for all patients
- Has a requirement that every patient be under the care of a member of the medical staff
- Provides 24-hour patient services
- Has in effect agreements with a home health agency for referral and transfer of patients to home health agency care when such service is appropriate to meet the patient's requirements
Service provided after the patient is admitted to the hospital. Inpatient stays are those lasting 24 hours or more.
Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.
A doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and is an employee of, or party to a contract with, a utilization management organization, and has responsibility for clinical oversight of the utilization management organization's utilization management, credentialing, quality management and other clinical functions.
Health care that is rendered by a hospital or a licensed or certified provider and is determined by EmblemHealth to meet all of the criteria listed below:
- It is provided for the diagnosis or direct care or treatment of the condition, illness, disease, injury or ailment.
- It is consistent with the symptoms or proper diagnosis and treatment of the medical condition, disease, injury or ailment.
- It is in accordance with accepted standards of good medical practice in the community.
- It is furnished in a setting commensurate with the member's medical needs and condition.
- It cannot be omitted under the standards referenced above.
- It is not in excess of the care indicated by generally accepted standards of good medical practice in the community.
- It is not furnished primarily for the convenience of the member, the member's family or the provider.
- In the case of a hospitalization, the care cannot be rendered safely or adequately on an outpatient basis or in a less intensive treatment setting and, therefore, requires the member receive acute care as a bed patient.
The fact that a provider has prescribed a service or supplies care does not automatically mean the service or supply will qualify for reimbursement under the EmblemHealth plan. To be eligible for reimbursement by EmblemHealth, all covered services must meet EmblemHealth's medical necessity criteria, described above.
Medically necessary with respect to Medicaid and Family Health Plus members means health care and services that are necessary to prevent, diagnose, manage or treat conditions that cause acute suffering, endanger life, result in illness or infirmity, interfere with a person's capacity for normal activity or threaten some significant handicap.
An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.
A type of health benefit plan that allows enrollees to go outside the health plan's provider network for care, but requires enrollees to pay higher out-of-pocket fees when they do. Also called Point of Service.
The process of obtaining advanced approval of coverage for a health care service or medication. The request for services is reviewed to assess medical necessity and appropriateness of elective hospital admissions and non-emergency outpatient services before the services are provided. Also called pre-authorization or pre-certification or pre-determination.
A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:
- Doctor of medicine
- Doctor of osteopathy
- Doctor of podiatric medicine
- Physical therapist
- Nurse midwife
- Certified and registered psychologist
- Certified and qualified social worker
- Nurse anesthetist
- Speech-language pathologist
- Clinical laboratory
- Screening center
- General hospital
- Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes
A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.
A request for inpatient review, made while the member is still in the facility, of a case that was denied on the basis of medical necessity.
A formal evaluation (prospective, concurrent or retrospective) of the coverage, medical necessity, efficiency or appropriateness of health services and treatment plans. Also called Coordinated Care.