Utilization Review Determinations Timeframe

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1 Utilization Review s Timeframe The purpose of this chart is to reference utilization review determination timeframes. It is not meant to completely outline the UR process. See Policy: Prospective, Concurrent, and Retrospective Utilization Review and Notification for more detailed instructions regarding UR determinations. Written requirements are applicable to determinations for fully insured HMO, POS and PPO products. With respect to self-insured groups, upon request, Tufts Health Plan will provide written notice of authorization. A provider is defined as a health care professional or facility. In all instances, Tufts Health Plan strives to conduct utilization review determinations and provide notice of these determinations within a reasonable period of time, appropriate to the medical circumstances. Note: This guide does not apply to Tufts Medicare Preferred HMO. Exception: This guide does apply to Tufts Medicare Preferred HMO members who are receiving services not covered by Medicare (i.e., hearing aid and unlimited pharmacy benefit after $150 per quarter has been exhausted). Services Provided in Rhode Island: A peer-to-peer attempt to communicate must be made/documented prior to the first level appeal determination, unless the provider requests a peer-to-peer communication prior to the initial adverse determination For prospective reviews of non-urgent and non-emergent health care services, a response within one (1) business day of the request for a peer-to-peer discussion For concurrent and prospective reviews of urgent and emergent health care services, a response within a reasonable period of time of the request for a peer to peer discussion Denial letter must include 180 day filing limit in which to file an appeal and RI appeal information Members receive copies of all denial letters even if not at financial risk for payment Review Type Decision Timeframe Extension Rules Prospective (pre-service) Review of non-urgent services UR that is performed prior to an admission or other course of treatment 2 working days of receipt of the necessary information **For prospective non urgent coverage requests pertaining to RI residents or any member receiving services in RI, a decision and notice must be completed no later than 15 business days of receipt of all necessary information, or prior to the proposed date of service if more than seven days, but not to exceed 15 Decision timeframe may be extended (if necessary) due to reasons outside control of Tufts Health Plan If after 10 calendar days from receipt of the request, the information received is inadequate for review, written notice must be sent to the member and provider. The written notice should specify that information must be received within 45 calendar days of receipt 1 of the written request by Tufts Health Plan. 1 The 45 calendar day extension to provide additional information applies only to member requests. Verbal notice to the provider within 24 hours of the decision insured products must be sent to the provider and member within 2 working days of the verbal notice, but no later than 15 calendar days from receipt of request Verbal notice to the provider within 24 hours of the decision Written notice must be sent to member and provider within 1 working day of verbal notice For services provided in RI see below. Revised 01/ Utilization Review s Timeframe

2 Prospective (pre-service) Review of urgent services UR performed for requests for coverage of medical care or treatment with respect to which the application of the time periods for making non urgent coverage determinations a) could seriously jeopardize the life or health of the member or the ability of the member to regain maximum function, or b) In the opinion of a physician with knowledge of the member s medical calendar days from the ASAP, taking account the medical exigencies and always within 2 working days of receipt of all necessary information, but no later than 72 hours of receipt of (i.e. for Thursday requests) Once the requested additional information is received, the determination must be completed within 2 working days. If the information is not received within the timeframe afforded the member and provider, an administrative denial may be rendered, if reasonable under the circumstances **Please note that for RI residents or The decision timeframe may be extended, if necessary, once for 48 hours if Tufts Health Plan is unable to render a determination based on lack of information required to complete review. Within 24 hours after receipt of the coverage request, verbal notice must be provided to the provider, specifying information required to complete the determination. The verbal notice must specify that the additional information must be received by Tufts Health Plan within 48 hours of the verbal request from Tufts Health Plan. Prospective review must be completed as soon as possible, taking Verbal notice to the requesting provider, must occur as soon as possible, taking account the medical exigencies and always within 24 hours of the decision, but no later than 72 hours of the receipt of the Verbal notice for authorizations must be completed by end of day Friday. insured commercial products must be sent to the requesting provider and the member within 2 working days of verbal notice If the written authorization Verbal notice to the requesting provider must occur as soon as possible, taking account the medical exigencies, and always within 24 hours of the decision but no later than 72 hours of receipt of the The provider must be verbally informed of the process of initiating the expedited appeals. Written Notice must be sent to the provider and member within 1 working day of verbal notice, but no later than 72 hours of receipt of the RI- Written denial notice must be sent within 1 working day of the decision, but no later than 72 Revised 01/ Utilization Review s Timeframe

3 condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the coverage ***The whole process of rendering the decision and completing the notice must not exceed 72 hours into account the medical exigencies, but no later than 48 hours after the earlier of: a) the receipt of information b) the end of the period afforded the member/provider to provide the information. **Please note that for RI residents or notice is requested by the member, provider or facility the written notice will be sent within 72 hours of the hours of the request for coverage. Concurrent review of urgent services UR performed during a hospital stay or other course of treatment. It includes review of requests for extended stays or additional services. UR performed for requests for coverage of medical care or treatment with respect to which the application of the time periods for making non urgent coverage determinations a) could seriously jeopardize the life or health of the member or the ability of ASAP, taking into account the medical exigencies and always within 24 hours of the receipt of the No extensions Verbal notice to the provider as soon as possible taking account the medical exigencies, but always within 24 hours of receipt of the request insured products must be sent to the provider and the member 24 hours of the receipt of the request If the written authorization notice is requested by the member, provider or facility, the written notice will be sent: 1. within 24 hours of the request, if the request was received at least 24 hours before the expiration of the currently certified period or treatment; or Verbal notice to the provider must occur as soon as possible taking into account the medical exigencies and always within 24 hours of the receipt of the Written notice must be sent to the provider and the member within 24 hours of receipt of For inpatient cases, written notice may be provided via facsimile. RI: Written notice to member/provider must be sent within 24 hours of the Revised 01/ Utilization Review s Timeframe

4 the member to regain maximum function, or b) In the opinion of a physician with knowledge of the member s medical condition, would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the coverage Note: Must always consider request concurrent urgent if request made at least 24 hours prior to the expiration of the prescribed period of time or number of treatments *** The whole process of rendering the decision and completing the notice must not exceed 72 hours Concurrent review of nonurgent services UR performed during a hospital stay or other course of treatment. It includes review of requests for extended stays or additional services. Decision must occur within 1 working day of receipt of the necessary information. The decision timeframe may be extended, if necessary due to reasons beyond the plan/ lack of information: If after the 10 calendar days the information received is inadequate for review, written notice must be sent to the member and provider specifying the information required to complete the review. 2. within 72 hours of the request, if the request was received less than 24 hours before the expiration of the currently certified period or treatments. Verbal notice to the provider must occur within1 working day of the decision insured products must be sent to the provider and the member within 1 working day of verbal notice, but no later than 15 calendar days from receipt of the Verbal notice to the provider must occur within 24 hours of the decision Verbal notice for denials must be completed by end of day Friday Written notice must be sent to the provider and member within 1 working day of verbal notice.). Revised 01/ Utilization Review s Timeframe

5 Retrospective (Post Service review) UR of services after they have been provided to the member Decisions must occur within 30 calendar days of the receipt of the request for coverage. The written notice must specify that the additional information be received by Tufts Health Plan within 45 calendar days of receipt 1 of the written request for additional information. If the additional information is received, the concurrent review must be completed within 1 working day. If the additional information is not received then the determination must be completed within 1 working day from the end of the period afforded the member or provider to provide the information. ** Please note that for RI residents or The decision timeframe may be extended for 15 calendar days, if necessary due to reasons beyond control of plan/lack of information. Within 30 calendar days, if the information received is inadequate for review, written notice must be sent to the member and provider, specifying the information required to complete the review. The written notice must specify that the additional information must be received by Tufts Health Plan within 45 Written notice may be sent to the provider and member within 30 calendar days (unless suspended- if suspended complete within 15 calendar days) of the receipt of the request for coverage For RI, the written notice must be sent within 1 working day of the decision. Written notice must be sent to the provider and member within 30 calendar days of receipt of the request for coverage (unless decision timeframe is suspendedif suspended complete within 15 calendar days). Revised 01/ Utilization Review s Timeframe

6 calendar days of receipt 1 of the written request for additional information. The time period for making the retrospective review determination is suspended from the date of the written notification to the earlier of: 1. The date on which Tufts Health Plan receives a response from the member, or; 2. The date established for furnishing the requested information (at least 45 calendar days) has expired The extension period (15 calendar days) within which the review determination must be completed begins from the date Tufts Health Plan received additional information (without regard to whether all of the requested information is provided) or, if earlier, the due date established by Tufts Health Plan for furnishing the requested information (at least 45 calendar days). If the requested information is received, the retrospective review determination, verbal and written notice must be completed within 15 calendar days. If the requested information is not received, an administrative denial can be rendered within 15 calendar days. Verbal and written notice must also be completed within 15 calendar days. Revised 01/ Utilization Review s Timeframe

7 **Please note that for RI residents or Revised 01/ Utilization Review s Timeframe

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