The file should be scored "Yes.” A person making the appeal decision is different from, and not subordinate to, an automated system.
HP 2017
FAQ Directory: Long-Term Services and Supports Distinction for Health Plans
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3.15.2017 UM 9 C: Scoring reviewer for appeals of system-made benefit denials Under UM 9, Element C, for an appeal of an initial benefit denial that was made by an automated system (e.g., claims or POS), where a person makes the appeal decision, should the file be scored “NA” or “Yes”?
1.15.2017 UM 7 B: Specific criterion referenced in a denial decision In UM 7, Element B, factor 2, organizations are required to reference the specific criterion used to make a denial decision. How specific does the criterion need to be?
The criterion referenced must be identifiable by name and must be specific to an organization or source (e.g., ABC PBM’s Criteria for Treatment of Hypothyroidism with Synthroid or CriteriaCompany Inc.’s Guidelines for Wound Treatment). If it is clear that the criterion is attributable to the organization, it is acceptable to state “our Criteria for XXX” (e.g., our Criteria for Treating High Cholesterol with Lipitor).
Note: This also applies to Element E and Element H in HPA and Element E in UM-CR.
HP 2016
12.15.2016 UM 9, Element D: Including Reviewers Names on Appeal Decision Letters Are organizations required to include reviewers’ names on appeal letters or verbally communicate to members that names are available upon request?
No. Organizations are not required to include reviewer names on the decision letter or verbally inform members that the information is available upon request. This language will be removed from UM 9, Element D in the March Policy update. Please note this requirement remains in UM 8, Element A. |
HP 2017
12.15.2016 Allowing Automatic Credit for UM 13, (UM 12 in HP 2017) Elements A and B for Interim Surveys Is automatic credit available for Interim Surveys for organizations that delegate UM 13 (UM 12 in HP 2017), Triage and Referral for Behavioral Healthcare, Elements A and B to an NCQA-Accredited/Certified health plan, MBHO or UM-CR?
Yes. Automatic credit is available for an Interim Survey if the organization delegates to an NCQA-Accredited/Certified health plan, MBHO or UM-CR. The delegate’s Accreditation/Certification Survey must include the specific elements or factors for which the organization seeks automatic credit. The organization is responsible for determining if delegated activities are covered in the scope of the delegate’s NCQA review.
HP 2017
11.15.2016 Opportunity to discuss a UM request Given CMS appeal regulations (at 42 CFR §422.580), may Medicare organizations give practitioners the opportunity to discuss a UM request prior to a UM decision, to meet the requirements of UM 7, Elements A, D and G?
10.15.2016 Pharmacists as Same-or-Similar Specialists May pharmacists be considered “same-or-similar” specialists?
10.15.2016 UM 7 Denial Notification Under UM 7, Element A, may organizations use a mass communication to notify treating practitioners of the opportunity to discuss a denial?
No. Organizations may not use mass communication for this element. Organizations have three options to notify practitioners of the opportunity to discuss a denial:
1. In the denial notification (included in the denial file).
2. By telephone (time and date of the denial included in the denial file).
3. In materials sent to the treating practitioner, informing the practitioner of the opportunity to discuss a specific denial with a reviewer (evidence that the practitioner was notified that a physician or other reviewer is available to discuss the denial included in the denial file).
HP 2017
10.15.2016 Types of pharmacy point of service claims included in UM 4, Element H file review What types of pharmacy point of service claims should be included in the scope of UM 4, Element H (UM 4, Element F in MBHO and UM-CR)?
The following denials (rejections) are included in the scope of UM 4, Element H (UM 4, Element F in MBHO and UM-CR):
- Claims for prescriptions that were refilled too soon.
- Claims for prescriptions with the incorrect dosage or quantity.*
- Claims that were denied because the organization’s reasonable filing procedures were not followed (e.g., lack of prior authorization).
* Inaccurately filed claims that were rejected because of incorrect dosage or quantity may be considered pending until a decision is made. If the request is denied, the claim is included in the scope of UM 4, Element H.
HP 2016