SPRING 2012 
  In This Issue:

Medicare and Medicaid Updates

Introducing Care360

EmblemHealth Injectable Drug Utilization Management Program Begins

Claims Corner

Utilization Review Criteria Update

Medical Director Availability After an Adverse Determination

Member Rights and Responsibilities

Provider Advisory Webinars a Success

CAHPS Member Satisfaction Surveys Are in the Field!

Behind the Scenes

Colorectal Cancer Screening

Medication Adherence for Chronic Conditions

Medical Management of COPD

Dental Hygiene Is Important

How to Help Your Patient With ADHD

Your Role in Slowing the Obesity Epidemic

Health and Wellness Programs

What Is a Health Outcome Survey?

Clinical Corner

News&Notes Archive

Medical Director Availability After an Adverse Determination

Our medical directors use established evidence-based criteria to evaluate requests for procedures and services including, but not limited to, surgery, testing or inpatient admissions, continued hospital stays, care in skilled nursing or rehabilitation facilities, requests for home care and durable medical equipment. They also use eligibility, benefits, medical necessity, and appropriateness of the type, level and setting of care criteria to assess requests.

In the event that a medical director issues an adverse determination after evaluating a request, verbal and written communications adhering to regulatory guidelines are delivered to the appropriate provider and member. Medical directors may rescind the adverse determination if additional information establishes medical necessity. If the adverse determination relates to a continued hospital stay, a reconsideration will be conducted only if the patient has not been discharged. If the patient has been discharged, a formal appeal must be filed with the Grievance and Appeals department as outlined for the specific member in the Dispute Resolution section of the Provider Manual:

A medical director is available to discuss adverse determinations, as well as the denial of pharmacy services, Monday through Friday, from 9 am to 5 pm. Please call 1-646-447-7479 for assistance.


|  Home  | |  Behind the Scenes  | |   Printer Friendly Page  | |  Print Full Issue  |