EmblemHealth and utilization review health care professionals make initial utilization review determinations for requested health care services that require prior approval. A "pre-service request" is a request for a service that must be pre-authorized by EmblemHealth.
Standard Pre-Service Review
Commercial/Child Health Plus
We will notify the member, their designee and their health care provider regarding a pre-service request within three business days after our receipt of the request if the information provided is or becomes complete. Notification will be in writing and by telephone to the member and provider. If EmblemHealth requires more information to make a determination, EmblemHealth will request such information within 15 days after its receipt of the request. EmblemHealth will provide at least 45 days to supply the information. At the end of the 45-day period, if the complete information is not received a determination will be made based on the information received within 15 calendar days from the expiration of the 45-day period.
We will notify the member, their designee and their health care provider regarding a pre-service request within three business days after our receipt of all the necessary information, but no more than 14 calendar days from receipt of request. Notification will be in writing and by telephone to the member and provider. This may be extended for up to 14 calendar days.
Providers and members will be notified in writing of a determination within 14 calendar days after we receive the request. This may be extended for up to 14 calendar days.
Commercial/Medicaid/Child Health Plus
EmblemHealth may reasonably require the provider or member to explain the medical reasons that give rise to a need for urgent care. If care has not yet been initiated, EmblemHealth will notify the provider and member of its decision regarding the urgent care claim within 72 hours from receipt of the request. Notification will be in writing and by telephone to the member and provider.
If we require more information to make a decision, then we will request the additional information within 24 hours after we receive the request. We will provide at least 48 hours to supply the information. Notification of our determination will occur within 48 hours of our receipt of the information or within 48 hours of the end of the time period we provide to supply the information. For Medicaid members this time frame may be extended for up to 14 calendar days.
Providers and members will be notified of a determination within 72 hours after we receive the request. If the request does not meet the criteria for an expedited request, the individual will be notified and the request will automatically be transferred to a standard request. A determination will be made within 14 days of the date that the request becomes a standard request.
Failure to make an initial utilization review determination within the specified times may be deemed as an adverse determination and subject to appeal/action appeal.
To be considered for payment, approval for elective services must be completed before services are rendered.
Admission Review and Concurrent Review
Once an initial inpatient stay or hospitalization has been issued, it is the responsibility of the facility to provide the managing entities (e.g., the EmblemHealth concurrent review nurse) with the necessary clinical updates. Facilities may submit concurrent review information to EmblemHealth via secure email or fax.
We may conduct concurrent reviews for members who are receiving care in an inpatient setting from the date of admission or for members who are receiving on-going care in an outpatient setting. Such concurrent review may result in our denial of payment based on eligibility, coverage or medical necessity for such covered care. For admissions that are reimbursed under a DRG methodology, concurrent utilization review may be conducted to determine medical necessity for quality purposes and discharge planning.
Once we have been notified of the admission, the concurrent review process will begin. The member's case will be assigned to a concurrent review nurse who will be responsible for requesting and initially reviewing all pertinent clinical information, including consulting with the treating physician and reviewing medical records, to determine the medical necessity of the services being provided. Concurrent review nurses perform telephonic or fax reviews with contracted hospitals. Concurrent review of the hospital stay may occur daily, depending upon the patient's acuity status.
The review frequency for any given case is determined by contractual agreements, payment methodology, discharge planning activity and the complexity of the patient's clinical condition. Concurrent review will not be conducted more frequently than is reasonably required to assess whether the health care services under review are medically necessary.
During the concurrent review, the concurrent review nurse maintains contact with the attending physician, hospital discharge planner, care manager if needed, patient and/or family members to address any anticipated medical services or sub-acute options (such as home care) and coordinates the appropriate referrals to participating alternate care facilities.
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.
Hospital utilization reports are reviewed by the Care Management department for analysis and system-wide action plan recommendations to the Quality Improvement Committee (QIC) through the Care Management Committee.
If the review is for post-acute hospital care and it meets medical necessity criteria and the member has the benefit, the service will be approved and would be monitored by either the Post-Acute Services department or the Continuing Care Services program.
The status of each case (whether approved, denied or pended) is included on the Concurrent Review Status Report posted to the secure provider site at www.emblemhealth.com for HIP-contracted hospitals and skilled nursing facilities.
Note: Medicare members do not require prior approval for hospice care. Hospice services are covered by FFS Medicare for Medicare members. For Medicare members receiving hospice services, EmblemHealth provides benefits for services not related to the terminal illness. Medicare members may revoke their hospice election at any time and return to the Plan to receive care related to their terminal illness.
(In the event the participating hospital does not notify the plan on admission)
Commercial/Child Health Plus
When a claim is submitted for an admission through the emergency department without the plan having received timely notification, records will be requested from the facility for an initial retrospective clinical review by the plan's Post-Service Review department. Upon the plan's request for medical records, the facility is given 30 days to submit the records. If records are received within that 45 calendar days from receipt of request, they are reviewed for medical, and a decision is made and communicated to the provider and the member in writing within 15 calendar days of receipt of the requested clinical information. If the case is denied (in whole or in part), appropriate appeal rights will be included.
When a claim is submitted for an admission through the emergency department without the plan having received timely notification, records will be requested from the facility for an initial retrospective clinical review by the plan's Post-Service Review department. Upon the plan's request for medical records, the facility is given 30 days to submit the records. A clinical determination will be made within 30 calendar days from receipt of request and is communicated to the provider and the member in writing within the determination time frame. If the case is denied (in whole or in part), appropriate appeal rights will be included.
Failure by the plan or the utilization review agent to make a determination within the time periods prescribed in this section shall be deemed to be adversely determined and subject to appeal.
Adverse Determination Process
If the Care Management program does not make an initial determination within the specified regulatory time frames of receiving all necessary information, the member, member's designee or the clinician on behalf of the member may exercise their next level of appeal rights regarding their service request.
If a service or continued use of a service is not medically necessary or appropriate based on a review of the clinical findings by the medical director, and following discussion with the attending physician, the plan medical director may make the decision to deny coverage of a service or further service for that episode of care. The nurse and/or medical director will attempt to contact the attending physician to allow the physician an opportunity to discuss the case with the medical director. The medical director will not make an adverse determination until all efforts have been made to resolve issues with the attending physician.
When the decision is made to deny coverage of a service or further service for an episode of care, an attempt will be made to contact the treating physician by telephone. The treating physician will be given the telephone number of the EmblemHealth physician reviewer or utilization review agent and is afforded the opportunity to speak with the reviewer about the denial.
The appropriate parties (physician, facility representative, patient, patient's family or legal guardian) will be notified in writing of an adverse determination. The notification will include the reasons for the adverse determination, including the clinical rationale and instructions on how to appeal the determination. This notice will also inform the clinician of the availability, upon request of the member or the member's designee, of the clinical review criteria relied upon to make the determination and specifies what, if any, additional information must be provided for the Plan or the review agent to render a decision upon the appeal. The adverse determination letter advises the physician about the opportunity to speak with the EmblemHealth medical director or utilization review agent who rendered the decision to discuss the denial along with a phone number where the medical director can be contacted.
Reconsideration Process/Peer-to-Peer Process
Whenever an adverse determination is rendered (a denial is issued), with or without the input of the clinician, the clinician has the opportunity to request a reconsideration (or peer-to-peer discussion) of the adverse determination. Such reconsideration shall occur within one business day of receipt of the request (except retrospective) for reconsideration and shall be conducted by discussion between the clinician and the EmblemHealth medical director who rendered the decision or a designated clinical peer reviewer.
When applicable, a reconsideration is available up until an appeal has been determined or the time frame for requesting an appeal has expired, whichever comes first. The member does not need to still be admitted to a facility or still be receiving the services for the conversation to occur. If the reconsideration is upheld (the original decision remains denied), the member/provider is still entitled to their appeal rights (unless the time frame has expired).
Note: This process applies to Medicare members ONLY when the requested service denied was in a participating inpatient acute facility and the denial was issued concurrently or retrospectively. All Medicare pre-service denials and all Medicare out-of-network denials, as well as any Medicare denials for other places of service, remain excluded from this process. The member/provider must continue to file an appeal or request a Medicare Reopen. An actual appeal must be submitted for Medicare members. Please see the Dispute Resolution chapters for more information.
Medicare Member Notices of Non-Coverage (GRIJALVA Process)
If the member no longer meets medical necessity criteria, notice of Medicare non-coverage will be issued to the Medicare member for continued skilled nursing facility (SNF) stays, home health care services or certified outpatient rehabilitation facility (CORF) services. If the notice of non-coverage is issued to a Medicare patient and the patient objects to the notice of non-coverage, the notice becomes effective two days after the day of issuance, unless the Medicare patient requests quality improvement organization (QIO) or IPRO for New York State review by noon of the first day following receipt of the notice. The QIO reviews the request and makes a determination within one working day of receipt of the request with the hospital or home care records, and notifies the member of its decision. If the QIO upholds the adverse determination of continued coverage, the member will become liable for all costs commencing at noon of the day following receipt of the QIO determination.
Restrospective Utilization Review
Initial review, post-discharge, of a case wherein the claim was denied for no prior approval or for which no concurrent review was performed:
- Whoever is responsible for managing the case (i.e., the managing entity) will perform the facility retrospective utilization review.
- The managing entity will render a decision within 30 days of receipt of the retrospective utilization review.
Note: While in the case of "no information denials," no true concurrent review is performed, such cases receive an initial clinical adverse determination (i.e., unable to establish medical necessity) and are therefore considered to have been reviewed. These denials, then, are subject to clinical appeals as indicated below, and not to retrospective utilization review.
Adverse Determination Based on Information Submitted
The following applies in the scenarios outlined below when we have received the necessary information to review the case for medical necessity:
Prior to Discharge (Facility Reconsideration)
If facility provides additional information after a denial has been issued but member has not yet been discharged:
- Plan/managing entity will perform concurrent review and uphold or rescind decision as indicated
- Reconsideration will be for all days for which information is supplied
Expedited Appeal Process
See the Dispute Resolution chapters of this manual: Commercial/CHP, Medicaid or Medicare.
Risk Identification and Management
The objectives of risk identification and management are to identify and create an awareness of possible risks that may be potentially harmful to members, visitors, or employees, and to reduce the probability of unplanned or unexpected financial loss. Through integration with the Quality Management process, the overall goals are to proactively prevent harm and identify trends.
All risk issues are referred to the Quality Management department for evaluation of potential quality of care issues. Those cases requiring immediate intervention are referred to a Medical Director, and substantial issues and trends are reported to the Clinical Quality Improvement Committee.