UM 5: Timeliness of UM Decisions

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1 UM 5: Timeliness of UM Decisions Element E: Timeliness of Pharmacy UM Decision Making Refer to Appendix 1 for points The organization adheres to the following time frames when making pharmacy UM decisions: 1. For urgent concurrent, within 24 hours of receiving the 2. For urgent preservice decisions, within 72 hours of receiving the 3. For nonurgent preservice decisions, within 15 calendar days of receiving the 4. For postservice decisions, within 30 calendar days of receiving the 5. For Medicare Part D urgent preservice decisions, within 24 hours of receiving the 6. For Medicare Part D nonurgent preservice decisions, within 72 hours of receiving the 7. For Medicare Part D postservice decisions, within 14 calendar days of receiving the Scoring Data source Scope of Look-back period Explanation 100% 80% 50% 20% 0% High (90-100%) on file Records or files Medium (60-89%) on file This element applies to First Surveys and Renewal Surveys. Low (0-59%) on file Factors 1-4 apply to commercial, Medicaid and Marketplace product lines and Medicare Part B drugs. NCQA s a random sample of up to 40 UM pharmaceutical denial files for evidence of timeliness of decision making. For First Surveys: 6 months. For Renewal Surveys: 12 months; 6 months for factors 5 7. THIS IS A MUST-PASS ELEMENT. This element applies to all pharmaceutical UM decisions directly related to requests by members (or by their authorized representatives) for authorization or payment for pharmaceuticals services, whether requests are based on benefits or on medical necessity, and whether they are approvals or denials. Dispute of file results NCQA conducts onsite file in the presence of the organization s staff and works with the organization to resolve any disputes during the onsite survey. An organization that is unable to resolve a dispute with the survey team must contact NCQA before the onsite survey is complete. File results may not be disputed, and may not be appealed once the onsite survey is complete.

2 Classification of UM pharmaceutical requests The organization uses the definitions below to classify UM pharmaceutical cases. Urgent request: A request for pharmaceutical services where application of the time frame for making routine or non-life threatening care determinations: Could seriously jeopardize the life, health or safety of the member or others, due to the member s psychological state, or In the opinion of a practitioner with knowledge of the member s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the Concurrent request: A request for coverage of pharmaceutical services made while a member is in the process of receiving the requested pharmaceutical services, even if the organization did not previously approve the earlier care. Nonurgent request: A request for pharmaceutical services for which application of the time periods for making a decision does not jeopardize the life or health of the member or the member s ability to regain maximum function and would not subject the member to severe pain. Preservice request: A request for coverage of pharmaceutical services that the organization must approve in advance, in whole or in part. Postservice request: A request for coverage of pharmaceutical services that have been received (e.g., retrospective ). Factors 1 7: Timeliness of pharmaceutical decision making The organization makes UM pharmaceutical decisions within the time frames specified in factors 1 7. NCQA measures the timeliness of pharmaceutical decisions from the date when the organization receives the request from the member or the member s authorized representative, even if the organization does not have all the information necessary to make the decision. If the organization has procedures for ongoing s of urgent concurrent care that it approved initially, the date of receipt is the date of. NCQA considers 24 hours to be equivalent to 1 calendar day and 72 hours to be equivalent to 3 calendar days. The organization documents the date when it receives the request, and the date of its decision, in the UM file. Under certain circumstances, the organization may extend the decision time frame. Refer to Related information. Exceptions This element is NA if: The organization and its delegates do not make UM decisions and all services are automatically approved. All purchasers of the organization s services carve out or exclude pharmaceutical management. Factors 1 4 are NA for Medicare Part D drugs. Factors 5 7 are NA for commercial, Medicaid and Marketplace product lines and Medicare Part B drugs. Related information Medicare Part B Drugs (Factors 1-4)

3 For guidance on drugs covered under Medicare Part B, refer to the Medicare Managed Care Manual, Chapter 4 - Benefits and Beneficiary Protections, 10.8 Drugs that are Covered Under Original Medicare Part B. Medicare Part D Drugs (Factors 5-7) For guidance on drugs covered under Medicare Part D, refer to the Medicare Prescription Drug Benefit Manual Chapter 6 Part D Drugs and Formulary Requirements, Covered Part D Drug. Alignment with CMS. Factor 5, Medicare Part D urgent preservice decisions. The time frame corresponds to the CMS expedited coverage determination time frame. Factor 6: Medicare Part D nonurgent preservice decisions. The time frame corresponds to the CMS standard coverage determination time frame. Factor 7: Medicare Part D postservice decisions. The time frame corresponds to the CMS request for reimbursement time frame. Receiving urgent requests after normal business hours. Due to the nature of urgent requests, the organization has procedures for accepting them after normal business hours. NCQA counts the time from the date when the organization receives the request, whether or not it is during business hours. The organization may process nonurgent requests during the next business day if it communicates this policy to members and practitioners. Postservice payment disputes. Postservice requests for payment initiated by a practitioner or a facility payment are not subject to if the practitioner or facility has no recourse against the member (i.e., the member is not at financial risk) and the practitioner or facility is not acting as the member s authorized representative. Exclude denials from such requests from the list for file sample selection. Approving alternative pharmaceuticals. If the organization approves an alternative to the pharmaceutical being requested and the treating practitioner or member does not request or agree to the alternative pharmaceutical the organization would be denying the pharmaceutical that was originally requested. However, if the treating practitioner agrees to the alternative and the pharmaceutical is authorized, the practitioner has essentially withdrawn the initial request, which is not considered a denial. Reclassification of requests that do not meet the definition of urgent care. If a request to extend a course of treatment beyond the prescribed time period or number of treatments previously approved by the organization does not meet the definition of urgent care, the request may be handled as a new request and decided within the time frame appropriate for the type of decision (i.e., preservice or postservice). Extending time frames for factors 1 4. Members or their authorized representative may agree to extend the decision-making time frame for urgent, preservice and postservice requests. The organization may also extend decision time frames under the following conditions Factor 1: Urgent concurrent requests. The request to extend urgent concurrent care was not made prior to 24 hours before the expiration of the prescribed period of time or number of treatments. The organization may treat the request as urgent preservice and make a decision within 72 hours. The request to approve additional days for urgent concurrent care is related to care not approved by the organization previously. The organization documents that it made

4 at least one attempt to obtain the necessary information within 24 hours of the request, but was unable to. The organization has up to 72 hours to make a decision. Factor 2: Urgent preservice requests. The organization may extend the urgent preservice time frame due to a lack of information once, for 48 hours, under the following conditions: Within 24 hours of receipt of the urgent preservice request, the organization asks the member or the member s representative for the information necessary to make the decision. The organization gives the member at least 48 hours to provide the information. The extension period, within which a decision must be made by the organization, begins: On the date when the organization receives the member s response (even if not all of the information is provided), or At the end of the time period given to the member to provide the information, if no response is received from the member or the member s authorized representative Factors 3, 4: Nonurgent preservice and postservice requests. If the request lacks clinical information, the organization may extend the nonurgent preservice or postservice time frame up to 15 calendar days, under the following conditions: The organization asks the member (or the member s representative) for the specific information necessary to make the decision within the decision time frame. The organization gives the member (or the member s authorized representative) at least 45 calendar days to provide the information. The extension period, within which a decision must be made by the organization, begins: On the date when the organization receives the member s response (even if not all of the information is provided), or At the end of the time period given to the member to supply the information, if no response is received from the member or the member s authorized representative. The organization may deny the request if it does not receive the information within the time frame, and the member may appeal the denial. Extension for other reasons. In a situation beyond the organization s control (e.g., waiting for an evaluation by a specialist), the organization may extend the nonurgent preservice and postservice time frames once, for up to 15 calendar days. Within 15 calendar days of a preservice request or 30 calendar days of a postservice request, the organization notifies the member or the member s authorized representative of the need for an extension, and the expected date of the decision. Extending time frames for Factors 5-7 Alignment with CMS: In accordance with the Medicare Prescription Drug Manual, Chapter 18: Part D Enrollee Grievances, Coverage Determinations, and Appeals 1 extensions are not allowed. Examples None.

5 Element F: Notification of Pharmacy Decisions Refer to Appendix 1 for points The organization adheres to the following time frames for notifying members and practitioners of pharmacy UM decisions: 1. For urgent concurrent decisions, electronic or written notification of the decision to members and practitioners within 24 hours of the 2. For urgent preservice decisions, electronic or written notification of the decision to members and practitioners within 72 hours of the 3. For nonurgent preservice decisions, electronic or written notification of the decision to members and practitioners within 15 calendar days of the 4. For postservice decisions, electronic or written notification of the decision to members and practitioners within 30 calendar days of the 5. For Medicare Part D urgent preservice decisions, electronic or written notification of the decision to members and practitioners within 24 hours of receipt of the 6. For Medicare Part D nonurgent preservice decisions, electronic or written notification of the decision to members and practitioners within 72 hours of receipt of the 7. For Medicare Part D postservice decisions, electronic or written notification of the decision to members and practitioners within 14 calendar days of receipt of the Scoring Data source Scope of Look-back period Explanation 100% 80% 50% 20% 0% High (90-100%) on file Records or files Medium (60-89%) on file This element applies to First Surveys and Renewal Surveys. Low (0-59%) on file Factors 1-4 apply to commercial, Medicaid, Marketplace product lines and Medicare Part B drugs. NCQA s a random sample of up to 40 pharmaceutical UM denial files for evidence of timeliness of notification. For First Surveys: 6 months. For Renewal Surveys: 12 months; 6 months for factors 5 7. THIS IS A MUST-PASS ELEMENT. This element applies to all pharmaceutical UM decisions directly related to requests by members or by their authorized representatives for authorization or payment for pharmaceuticals, whether requests are based on benefits or on medical necessity, and whether they are approvals or denials. Dispute of file results NCQA conducts onsite file in the presence of the organization s staff and works with the organization to resolve any disputes during the onsite survey. An organization that is unable to resolve a dispute with the survey team must contact NCQA before the onsite survey is complete. File results may not be disputed, and may not be appealed once the onsite survey is complete. Factors 1 7: Timeliness of pharmacy notification

6 The organization notifies practitioners and members of UM pharmaceutical decisions within the times specified in factors 1-7. NCQA measures timeliness of pharmaceutical notification from the date when the organization receives the pharmaceutical request from the member or the member s authorized representative, even if the organization does not have all the information necessary to make a decision. Exceptions This element is NA if: The organization and its delegates do not make UM decisions and all services are automatically approved. All purchasers of the organization s services carve out or exclude pharmaceutical management. The organization is not required to notify the member of a concurrent decision (factor 1) or a postservice decision (factor 4) if the member is not at financial risk. Factors 1 4 are NA for Medicare Part D drugs. Factors 5 7 are NA for commercial, Medicaid and Marketplace product lines and Medicare Part B drugs. Related information Medicare Part B Drugs (factors 1-4) For guidance on drugs covered under Medicare Part B, reference the Medicare Managed Care Manual, Chapter 4 - Benefits and Beneficiary Protections, 10.8 Drugs that are Covered Under Original Medicare Part B. Medicare Part D Drugs (factors 5-7) For guidance on drugs covered under Medicare Part D, reference the Medicare Prescription Drug Benefit Manual Chapter 6 Part D Drugs and Formulary Requirements, Covered Part D Drug. Alignment with CMS time frames Factor 5: Medicare Part D urgent preservice decisions. The time frame corresponds to the CMS expedited coverage determination time frame. Factor 6: Medicare Part D nonurgent preservice decisions. The time frame corresponds to the CMS standard coverage determination time frame. Factor 7: Medicare Part D postservice decisions. The time frame corresponds to the CMS request for reimbursement time frame. Previously approved care. If the organization has procedures for ongoing of urgent concurrent care that it approved initially, the notification period begins on the day of the. The organization documents the date of the ongoing, the decision and the notification in the UM denial file. Factors 1, 2: Notifying the treating or attending practitioner. NCQA does not require the organization to notify a member of an urgent preservice or urgent concurrent decision. The organization may notify only the attending or treating practitioner, because NCQA considers the attending or treating practitioner to be acting as the member s representative. Oral notification. The organization may provide initial oral notification of a denial decision within 24 hours of an urgent concurrent request or within 72 hours of an urgent preservice The organization records the time and date of notification

7 and the staff member who spoke with the member or practitioner. Electronic or written notification must be provided no later than 3 calendar days after the oral notification. For urgent concurrent denials, the organization may inform the hospital Utilization Review (UR) department staff of its decision, with the understanding that staff will inform the attending/treating practitioner. Failure to follow filing procedures. If the member or member s authorized representative does not follow the organization s reasonable filing procedures for requesting preservice or urgent concurrent services, the organization notifies the practitioner or member of the failure and informs them of the procedures to follow when requesting services. For urgent preservice and concurrent decisions, the organization notifies the practitioner or member within 24 hours of receiving the request for services. For nonurgent preservice decisions, the organization notifies the practitioner or member within 5 calendar days of receiving the request for services. Notification may be oral, unless the practitioner or member requests written notification. Extending the decision time frame If the decision time frame is extended, the notification time frame is extended, as well. Refer to Element E: Related information. Examples None.

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