Member Appeals: Fee-for-service Benefits Presented by: Jessica Chislett, Access Stakeholder Relations Specialist Jami Gazerro, Operations Section Manager April 2020 1
General Information Meeting scope • Roles • Participation • 2
Our Vision Health First Colorado members can access: the right health services, at the right time, in the right setting, for the right duration. 3
Appeals 4
Member Appeals Members may request an appeal when they don't agree • with a decision about services that were requested. Services may have been partially approved or denied. • 5
Fee-For-Service Benefits Covered Breast & Cervical Cancer • Physical Therapy/ • Program (BCCP) Occupational Therapy/ Client Over-Utilization • Speech Therapy Program (COUP) Radiology • Dental • Private Duty Nursing (PDN) • Durable Medical • Personal Care • Equipment (DME) Surgery • Long Term Home Health • Women's Health • (LTHH) Laboratory • Non-Emergent Medical • Early and Periodic • Transportation (NEMT) Screening, Diagnostic, Orthodontia • and Testing (EPSDT) 6
Other Types of Appeals Eligibility • Pharmacy • Waivers • Managed Care • 7
Appeals Team 8
Jami Gazerro Operations Section Manager 9
Lily Linares Appeals Navigator 10
Joey Gallegos Appeals Representative 11
Whitney McOwen Compliance & Policy Advisor 12
Russ Zigler Compliance & Policy Advisor 13
The Appeals Process 14
Request for Service 15
Request for Service Vendor reviews the Provider submits a Provider PAR and decides Prior Authorization Member and determines that a Whether to Request (PAR) provider notified specific service or approve, to vendor in writing of treatment is partially approve, (e.g., eQHealth, the decision needed or deny the Intelliride) request 16
Request for Service Provider submits a Vendor reviews the Provider Prior Authorization PAR and decides Member and Determines that a Request (PAR) whether to provider notified specific service or to vendor approve, in writing of treatment is (e.g., eQHealth, partially approve, the decision needed Intelliride) or deny the request 17
Medical Necessity 10 CCR 2505-10 Section 8.076(8) - Medical necessity means a Medical Assistance program good or service: a. Will, or is reasonably expected to prevent, diagnose, cure, correct, reduce, or ameliorate the pain and suffering, or the physical, mental, cognitive, or developmental effects of an illness, condition, injury, or disability. This may include a course of treatment that includes mere observation or no treatment at all; b. Is provided in accordance with generally accepted professional standards for health care in the United States; 18
Medical Necessity c. Is clinically appropriate in terms of type, frequency, extent, site, and duration; d. Is not primarily for the economic benefit of the provider or primarily for the convenience of the client, caretaker, or provider; e. Is delivered in the most appropriate setting(s) required by the client's condition; f. Is not experimental or investigational; and g. Is not more costly than other equally effective treatment options. 19
Early and Periodic Screening, Diagnostic, and Treatment Members 20 and younger • Peer-to-Peer review before a PAR is denied or partially • approved. Allows additional information to be shared to support • medical necessity. 20
Request for Service Vendor reviews the Provider submits a Provider PAR and decides Prior Authorization Member and Determines that a whether to Request (PAR) provider notified in specific service or approve, to vendor writing of the treatment is partially approve, (e.g., eQHealth, decision needed or deny the Intelliride) request 21
Denial or Partial Approval If the request is denied or partially approved, the • member will receive a letter outlining the decision and the reason why. This decision is based on clinical documentation • submitted and signed by a physician licensed to diagnose and treat. 22
Denial or Partial Approval The request may have been denied because the benefit • or service requested: • Not a covered benefit • Benefit limitations and requirements • Does not meet medical necessity criteria • Adequate documentation was not submitted to demonstrate needs. 23
Provider Options and Member Appeal Request 24
Initiating the Appeal Submit request to The Office of The Office of appeal within 60 Administrative Member decides to Administrative days of the date on Courts informs appeal the denial Courts receives the letter. This can parties in writing or partial approval request and be via mail, fax, of the date, time, of the request schedules a in-person, email, and location of hearing. or online. the hearing Provider submits a Provider decides to Vendor request for seek additional determines reconsideration or review of the whether to change Peer-to- decision decision Peer (eQHealth) 25
Provider Options Peer-to-Peer or Reconsideration • May result in the PAR decision being changed • 26
Initiating the Appeal The Office Submit request The Office of Administrative Member decides to appeal within of Administrative Courts to appeal the 60 days of the date Courts informs parties in denial or partial on the letter. This receives request writing of the approval of the can be via mail, and schedules date, time, and request fax, in-person, a hearing. location email, or online. of the hearing Provider submits Provider decides a request Vendor determines to seek for reconsideration whether to additional review or Peer-to- change decision of the decision Peer (eQHealth) 27
Provider Peer-to-Peer Providers can request a review of a PAR that has been • denied or partially approved. Reviews requested on the basis of medical necessity or • for technical reasons. Share additional information and discuss the PAR with • the physician reviewer. 28
Provider Reconsideration Providers can request a review of a PAR that has been • denied or partially approved. Reviews requested on the basis of medical necessity or • for technical reasons. If the request was denied for medical necessity reasons, • a different physician will conduct the review. 29
Initiating the Appeal Submit request to The Office of The Office of appeal within 60 Administrative Member decides to Administrative days of the date on Courts informs appeal the denial Courts receives the letter. This can parties in writing or partial approval request and be via mail, fax, of the date, time, of the request schedules a in-person, email, and location of hearing. or online. the hearing Provider submits a Provider decides to Vendor request for seek additional determines reconsideration or review of the whether to change Peer-to- decision decision Peer (eQHealth) 30
Member Process Denial and partial approval letters include: • Information about what was denied and why • • Member Appeal Rights Non-discrimination Notice • Language Help • • Member decides whether to appeal • Providers should not advise members to postpone requesting an appeal 31
Initiating the Appeal Submit The Office of Member request to appeal The Office of Administrative decides to appeal within 60 days of Administrative Courts informs part the denial or the date on the Courts receives ies in writing of partial approval of letter. This can be request and the date, the request via mail, fax, in- schedules a time, and location person, email, or hearing. of the hearing online. Provider Provider submits a request decides to seek Vendor determines for reconsideration additional review whether or Peer-to- of the decision to change decision Peer (eQHealth) 32
Initiating the Appeal If they disagree with the PAR decision, members can • decide to appeal. Members must ask for an appeal in writing, which must • include: Name, address, phone number, and Medicaid • number; Why they are requesting a hearing; and • What they are appealing. • 33
Initiating the Appeal Mail, fax, online, email, or in-person submission • of appeal to: Office of Administrative Courts, 1525 Sherman • Street, 4th Floor, Denver, CO 80203 Fax:303-866-5909 • Courtlink - http://socgov12- • site.force.com/CourtLinkGS. 34
Initiating the Appeal Online 35
Initiating the Appeal Online 36
Initiating the Appeal Online 37
Initiating the Appeal Online 38
Initiating the Appeal Online 39
Initiating the Appeal Online 40
Initiating the Appeal Online 41
Initiating the Appeal Online The appeal request must be received online by the Office of Administrative Courts within 60 calendar days of the date on the denial/partial approval letter received. 42
Recommend
More recommend
