Health Care Management Policy and Procedure

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1 Utilization Management... 2 Pharmaceutical Management... 3 Member Clinical Appeal and Independent External Review ASO Groups Not Voluntarily Complying with the Illinois External Review Act (Federal)... 7 Member Clinical Appeal and Independent External Review Fully Insured & ACA- Regulated ASO Groups Voluntarily Complying with the Illinois External Review Act (State) Member Non-Clinical Appeals A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association BCBSIL Provider Manual Rev 8/14 1

2 Utilization Management BCBSIL Provider Manual Rev 8/14 2

3 Policy Name: Pharmaceutical Management Policy Number: Utilization Management - 2 Effective Date: 1/1/01 Revision Date: 03/01/14 Review Date: 03/01/14 Approval Signature: Vice President & Chief Medical Officer Divisional Senior Vice President Network Management HMOI, BA HMO, BlueChoice, PPO Exchange, and Blue Precision Approved QI: 3/12/14 Approved P&P: 2/13/14 Policy: Blue Cross and Blue Shield of Illinois (BCBSIL) has delegated Prime Therapeutics as its Pharmacy Benefits Management (PBM) vendor and the Prime Therapeutics National Pharmacy and Therapeutics Committee (P&T Committee) will serve as a recommending body to develop, maintain and promote a formulary system based on safety, efficacy and cost of pharmaceutical care. BCBSIL members have access to an open formulary for prescription medications. Prescriptions are generally subject to varying payment levels for generic, formulary brand and non-formulary brand drugs. Purpose: To ensure the prescription drug formulary system is based on safety, efficacy and cost of pharmaceutical care. To create value for both providers and members by developing and maintaining a select list of products that benefits both patient care and program costs. To review, update and distribute pharmaceutical management procedures annually and when changes are made. Guidelines: I. The P&T Committee will: Develop policies regarding the evaluation, selection and therapeutic use of pharmaceuticals. Evaluate and select pharmaceutical products for formulary inclusion based on established criteria. Review new entities that represent significant therapeutic advances with development of guidelines for use, when appropriate, within six months of Food and Drug Administration (FDA) approval. Review agents and major therapeutic classes in a timely manner. Re-evaluate agents and therapeutic classes when new developments occur. Promote the use of FDA approved A rated generic drugs as appropriate, including consideration of critical drugs (i.e., those drugs with a narrow therapeutic index where generic substitution may not be in the best interests of the patient). BCBSIL Provider Manual Rev 8/14 3

4 Pharmaceutical Management Page 2 of 4 Provide recommendations or assistance in the development of appropriate-use programs designed to meet the needs of all managed care professionals. Serve in an evaluative, educational, and advisory capacity to BCBSIL in matters pertaining to drug therapy management. Develop, review and update the Prescription Drug Formulary as new pharmaceutical information becomes available. Review the results of drug use evaluation and drug utilization review programs and make recommendations to optimize appropriate drug use. Disseminate information, actions and approved recommendations to committee members, PBM clients, providers and others as appropriate. Procedure: I. P&T Committee Organization and Operation A. The P&T Committee will be composed of at least the following members: 1. Physicians 2. Pharmacists 3. Pharmacologists 4. Other healthcare professionals B. An independent physician will serve as Chairperson. C. The committee meets a minimum of once a quarter. D. The minutes of the committee meetings will be prepared by the secretary and maintained in the permanent records at the PBM. E. The actions of the committee will be communicated to all appropriate healthcare personnel. F. The committee will be organized and operated in a manner that ensures the objectivity and credibility of its recommendations. G. The committee will establish and enforce a conflict of interest policy and confidentiality policy with respect to committee recommendations and actions. II. The committee maintains the following guidelines and policies: A. Basis of Recommendations: 1. Drugs will be reviewed for clinical efficacy and safety. Other factors which may impact the therapeutic value of a drug are considered. Those factors include but are not limited to: a) Convenience and ease of administration b) Relevant clinical guidelines or treatment protocols c) Utilization patterns d) Medical need e) AWP costs (Average Wholesale Price) B. Voting Process 1. If any committee member determines there is a conflict of interest regarding the vote for a particular agent, the member must voice a disclaimer before the discussion begins and abstain from the voting process if deemed necessary. BCBSIL Provider Manual Rev 8/14 4

5 Pharmaceutical Management Page 3 of 4 2. A quorum of two-thirds of the voting members of the PBM P&T Committee is needed to vote on decisions. 3. A decision may be revisited at the discretion of the PBM P&T Committee. III. Criteria for Drug and Therapeutic Class Review: A. Request of P&T Committee member, client or network physician. B. An individual member or provider may request PBM P&T Committee action on a particular drug or therapeutic class of drug by contacting their health plan or employee benefit administrator. The health plan or employer will communicate the request directly to the PBM. C. New drug entity - preference will be given to drugs reviewed by the FDA on a priority basis. D. Any currently marketed drug that has not been previously reviewed or has received a new indication. E. Must have a published average wholesale price (individual drug). IV. Pharmaceutical Patient Safety Issues A. The PBM maintains a system to identify, classify and notify pharmacists, providers and members at the point of dispensing of the following: 1. Drug to drug interactions for identified severity levels. 2. Specific drug to drug interactions when they meet the identified severity levels. B. The PBM maintains a system to identify and notify members and prescribing practitioners affected by: 1. FDA class I recall which must include an expedited process for prompt identification and notification of members and prescribing practitioners. a) The PBM will notify members and prescribing physicians with a notification letter within 7 business days of the Class I recall. b) The PBM will also contact the client regarding the recall. c) The notification process will begin within 1-2 business days of FDA notification to the PBM. 2. FDA Class II recall or voluntary drug withdrawals from the market within 30 calendar days of the FDA notification. C. The PBM notifies physicians of drug recalls through the mailing of a Drug Safety Alert. The notification includes a list of their patients who recently filled a prescription for the medication. V. Pharmaceutical Restrictions and Preferences A. BCBSIL maintains an open Prescription Drug Formulary. 1. All FDA-approved prescription medications are covered at varying payment levels with some exceptions (e.g. cosmetic alteration drugs, non-self injectables). a) Therapeutic substitution is a voluntary program that requires consent of the prescribing physician and the member at the point of dispensing. b) Generic substitution is encouraged but is not mandatory. Generic products are generally covered at a lower payment level than the brand equivalent. c) Prior authorization is required on select medication categories. BCBSIL Provider Manual Rev 8/14 5

6 Pharmaceutical Management Page 4 of 4 d) Step therapy is required on select medication categories. 2. Prescriptions are covered up to a 34 day supply for one payment. Exceptions to this limit are allowed for the following reasons: a) Change of dosage requiring a larger quantity. b) Medication lost. c) Vacation supply. d) Delay in mail-order processing. 3. BCBSIL provides the formulary and pharmaceutical management procedures to contracted practitioners and medical groups for distribution to their practitioners annually, and when changes are made. 4. All changes to the formulary are communicated to practitioners via the provider newsletter. Changes to the pharmaceutical management procedures are communicated via BlueReview and BCBSIL s Web site, 5. A current version of the formulary is maintained and available to practitioners and members on BCBSIL's Web site, BCBSIL Provider Manual Rev 8/14 6

7 Policy Name: Member Clinical Appeal and Independent External Review ASO Groups Not Voluntarily Complying with the Illinois External Review Act (Federal) Policy Number: Utilization Management - 10 Effective Date: 7/1/03 Revision Date: 12/1/13 Review Date: 12/1/13 Approval Signature: Vice President and Chief Medical Officer HMOI, BA HMO, PPO, Blue Precision Replaces HMO Admin 47 & MC UM 3 Approved QI: 12/4/13 Approved P&P: 11/14/13 Policy: Blue Cross and Blue Shield of Illinois (BCBSIL) will review member clinical appeals resulting from an adverse determination for members in ASO groups not voluntarily complying with the Illinois External Review Act in a thorough, appropriate and timely manner. A member, his/her authorized representative, physician, facility, or other health care provider may request an appeal on behalf of the member either verbally or in writing. Purpose: To ensure thorough, timely and appropriate handling of member appeals. Guidelines: A Member, his/her authorized representative, physician, facility, or other health care provider may request an appeal on behalf of the member. If a member selects an authorized representative to act on his/her behalf, written authorization from the member is required at the time of the request. All clinical appeals are reviewed by a board-certified clinical peer, in a same or similar specialty that typically manages the condition or care in question, who was not involved in the original decision and not a subordinate of the original decision-maker. The decision of the clinical peer is binding. The Member may appeal to the Illinois Department of Insurance at any time. The appeal process does not imply that BCBSIL is required to pay for health care services not covered under the Member s benefit plan document. Members will be allowed to have continued coverage for ongoing services under their insurance policy pending the outcome of an internal appeal. This applies to covered services only; BCBSIL will not reduce or terminate an ongoing course of treatment without providing advance notice and an opportunity for advance review. BCBSIL may accept all member appeals regardless of the 180 day submission time frame required by law. BCBSIL Provider Manual Rev 8/14 7

8 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 2 of 27 Definitions: 1. Adverse Determination a determination by a health carrier or its designee utilization review organization that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been reviewed and, based upon the information provided, does not meet the health carrier s requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness, and the requested service or payment for the service is therefore denied, reduced, or terminated. 2. Clinical Appeal an appeal regarding an Adverse Determination of a service that is a covered benefit in the benefit plan document, or could be considered to be a covered benefit depending upon the circumstances, when the basis for the appeal is clinical in nature. Examples of clinical appeals include: Appeals involving an Adverse Determination of services based on the lack of medical necessity. Appeals regarding an experimental or investigational service. Appeals regarding a cosmetic procedure when the basis for the appeal is that the service is needed for other than cosmetic reasons. Appeals for access to an out-of-network practitioner or provider when the basis for the appeal is that access to a practitioner or provider with appropriate clinical expertise has not been provided. Note: Appeals are not considered to be clinical appeals when there is no clinical basis for the appeal. 3. Clinical Peer a practitioner or health care professional who must: Hold a current active, unrestricted license to practice medicine or a health profession in a state or territory of the United States Unless expressly allowed by state or federal law or regulation, are located in a state or territory of the United States when conducting an appeals consideration; Be board certified by a specialty board approved by the American Board of Medical Specialties (doctors of medicine); or the Advisory Board of Osteopathic Specialists from the major areas of clinical services (doctors of osteopathic medicine); (Note: Board certification requirement is not applicable to provider types other than doctors of medicine and doctors of osteopathic medicine.) Be in the same profession and in a similar specialty as typically manages the medical condition, procedure, or treatment under review. Neither be the individual who made the original Adverse Determination, nor the subordinate of such an individual. Note: A physician reviewer may at any time defer to evaluate an appeal if he/she feels that they do not have the specific clinical expertise to evaluate a particular service. 4. Expedited Appeal a pre-service or concurrent request to change an Adverse Determination for urgent care. 5. External Peer Review a request for an independent, external review of the final adverse determination made through the internal appeal process. BCBSIL Provider Manual Rev 8/14 8

9 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 3 of Final Adverse Determination an adverse determination involving a covered benefit that has been upheld by a health carrier, or its designee utilization review organization, at the completion of the health carrier s internal grievance process procedures as set forth by the Managed care Reform and Patient Rights Act. 7. Health Care Services Any service included in the provision of medical care, as outlined in the Member s benefit plan documents, for the purpose of preventing, alleviating, curing or healing human illness or injury. 8. Non-Urgent Appeal a pre-service or post-service appeal that does not meet the urgent care expedited appeal criteria. 9. Post-service Appeal a request to change an adverse determination for care or services that have already been received by the member. 10. Pre-service Appeal a request to change an adverse determination for care or services that must be approved in whole or in part in advance of the member obtaining care or services. 11. Standard Clinical Appeal an appeal regarding denial of a service that is a covered benefit in the certificate of health care benefits, or could be considered to be a covered benefit depending upon the circumstances, when the basis for the appeal is clinical in nature. Examples of clinical appeals include: Appeals involving an adverse determination of services based on the lack of medical necessity/medical appropriateness. Appeals regarding an experimental or investigational service. Appeals regarding a cosmetic procedure when the basis for the Appeal is that the service is needed for other than cosmetic reasons. Appeals for access to an out-of-network practitioner or provider when the basis for the Appeal is that access to a practitioner or provider with appropriate clinical expertise has not been provided. 12. Urgent Care a request for medical care or treatment with respect to which the application of the time-periods for making non-urgent care determinations: Could seriously jeopardize the life or health of the member, or the member s ability to regain maximum function, based on a prudent layperson s judgment, or In the opinion of the practitioner 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 request. Procedure: Urgent Care/Expedited Pre-service and Concurrent Appeals: 1. An urgent care/expedited appeal may be requested verbally or in writing. 2. For provider urgent/expedited clinical appeals, the provider is presumed to be appealing on behalf of the member. BCBSIL Provider Manual Rev 8/14 9

10 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 4 of A member authorization is not required for provider urgent/expedited clinical appeals. 4. The decision time frame for the appeal request is as expeditiously as the medical condition requires but no later than the decision time frame identified below. a. The decision time frame for completion of urgent care/expedited pre-service and concurrent appeal requests must be made no later than 72 hours from receipt of the appeal request followed by written notification within three (3) calendar days. 5. Following receipt of a verbal or written Urgent care/expedited pre-service or concurrent Appeal request, via fax or telephone call, the designated Appeal staff will review the information received for completeness within 24 hours of receipt request. a. If incomplete documentation has been submitted. b. Within 24 hours of receipt of the appeal request, the appeal staff verbally informs party of the specific information necessary to complete the appeal request. c. The party shall be afforded a reasonable amount of time, taking into account the circumstances, but not less than 48 hours to provide the specified information. d. The appeal is pended and initiated upon receipt of the requested information. e. If the requested information is not received within 48 hours, a determination is made based on the available information, with verbal and written notification provided to the requesting provider, member, facility and/or the party filing the appeal. f. The appropriate applications are updated and the complete file is maintained in the BCBSIL corporate electronic record storage system (Enterprise Appeal Application). i. The provider, member, and/or facility have the right to submit additional information related to the appeal request under review. ii. If the documentation received was forwarded by a physician or a facility on behalf of the member the additional information should be sent to the member on the same date that the information is received at BCBSIL iii. If the request is related to a case under review by the Medical Management department, the clinical documentation system (Alineo) is reviewed for additional information. iv. All information received will be considered during the appeal process regardless of whether it was reviewed during the initial review. v. Information is evaluated by the designated appeal physician as appropriate. 6. If the designated appeal physician overturns the original denial: a. Verbal notification of the decision is provided to the requesting provider, member, facility and/or the party filing the appeal. if applicable, is provided within 72 hours of request. Written notification is completed within the following three (3) calendar days of verbal notification and includes all elements referenced in #7, below. (See Attachments) b. The appropriate applications are updated and the complete file is maintained in the BCBSIL corporate electronic record storage system (Enterprise Appeal Application). BCBSIL Provider Manual Rev 8/14 10

11 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 5 of The designated appeal physician does not overturn the original denial during the evaluation: a. Appeal file is immediately forwarded to an internal or external clinical peer for review. b. If an internal clinical peer is available, note the clinical peer identified to review the appeal. i. If an external clinical peer is required. ii. Complete the Peer Service Request Form indicating the specialty required and that the decision is needed within 24 business hours. iii. The pertinent medical information is sent in the most expeditious manner possible (via the Web portal, via fax, etc.) with the request. 8. Upon receipt of the clinical peer decision: a. Designated appeal staff forwards appeal request and clinical peer decision to designated appeal medical director for review. b. Designated appeal medical director reviews and forwards case to designated appeal staff to complete verbal and written notification c. Designated appeal staff performs verbal notification of the decision to the member or the party filing the appeal, the attending physician and the ordering provider and/or facility, within the decision time frames applicable to appeal. Refer to above guidelines for decision time frames. At the time of notification, party will also be notified of their rights to additional levels of appeal, as applicable. d. Designated appeal staff issues written notification of the decision to all parties. The written notification will include: i. The appeal determination, ii. The principal reason for the determination, iii. A reference to the benefit provision, guideline, protocol or other similar criterion on which the appeal decision was based, iv. The clinical rationale, which includes an understandable summary of the medical criteria, benefit provision, guideline or protocol used to make the determination, v. A statement that the specific medical criteria or benefit provision used in making the determination will be provided upon request, vi. The titles and qualifications of the individual(s) participating in the appeal review, vii. A statement that copies of all documents relevant to the member s appeal will be provided upon request. viii. If the appeal decision maintains the original adverse decision and the appeal request is from a member of an ACA-regulated ASO Group who has elected to follow the Federal external review process, the written notification will also include: A description of the procedure for requesting an external independent review, The time frame for submission of an external appeal request, The member s right to designate someone to act on his/her behalf, Language confirming the external reviewer s decision is binding, A statement that benefits beyond those included in the benefit certificate are not eligible for external review and A statement that there is no cost to the member should they request external review. A description of further appeal rights if applicable. BCBSIL Provider Manual Rev 8/14 11

12 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 6 of 27 Note: If the appeal decision maintains the original adverse decision and the appeal request is from a member of an ACA-regulated ASO Group who has not hired BCBSIL to handle its external review process, then the written notification will be customized to meet the needs of the Group. (See Attachments) The appropriate applications are updated and the complete file is maintained in an electronic format within the BCBSIL corporate electronic record storage system (Enterprise Appeal Application). The complete file can also be maintained in a secure area including but not limited to a locked cabinet. Non-urgent Pre-service and Post-service Appeals 1. Time frame for completion of non-urgent post-service clinical appeal requests is 30 calendar days from receipt of the request and pre-service requests is 15 calendar days from the receipt of the request to notification of the decision. a. Following receipt of a verbal or written non-urgent pre-service or post-service clinical appeal request, the designated appeal staff will review all information received. b. If insufficient information has been submitted, the Request for Additional Information letter is mailed. (See Attachment) This request is submitted to the provider in addition to the member, facility and or the party filing the appeal. c. The party shall be afforded 45 calendar days from receipt of the notice within which to provide the specified information. d. The appeal is pended and initiated upon receipt of the requested information. e. If the requested information is not received within the specified time frame a determination is made based on the available information, with verbal and written notification provided to the requesting provider, member, facility and/or the party filing the appeal. f. The appropriate applications are updated and the complete file is maintained in the BCBSIL corporate electronic record storage system (Enterprise Appeal Application). i. The provider, member, and/or facility have the right to submit additional information related to the appeal request under review. ii. If the documentation received was forwarded by a physician or a facility on behalf of the member the additional information should be sent to the member on the same date that the information is received at BCBSIL iii. If the request is related to a case under review by the Medical Management department, the clinical documentation system is reviewed for additional information. 2. All information received will be considered during the appeal process regardless of whether it was reviewed during the initial review. If the documentation received was forwarded by a physician or a facility on behalf of the member the additional information should be sent to the member on the same date that the information is received at BCBSIL. BCBSIL Provider Manual Rev 8/14 12

13 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 7 of The designated appeal physician evaluates the appeal request. a. The designated appeal physician takes all information into account during evaluation of the appeal without regard to whether such information was submitted or considered in the initial review of the request for health services. b. The designated appeal physician overturns the original denial. c. Designated appeal staff performs verbal and written notification of the decision to the member, physician and facility, if applicable, is provided. (See Attachments) d. The appropriate applications are updated and the complete file is maintained in an electronic format within the BCBSIL corporate electronic record storage system the (Enterprise Appeal Application). 4. The designated appeal physician does not overturn the original denial during evaluation: a. Appeal file is forwarded to an internal or external clinical peer for review. b. If the designated appeal physician s documentation indicates an internal clinical peer is available, note the clinical peer identified to review the appeal. c. If an external clinical peer is required: i. Complete the Peer Service Request Form indicating the specialty required and the time frame for completion. ii. The pertinent medical information is sent to the external clinical peer via Web portal or fax and/or overnight mail. 5. Upon receipt of the clinical peer decision, written notification of decision to the member, physician and facility, if applicable, will be sent which will include: a. The appeal determination, b. The principal reason for the determination, c. A reference to the benefit provision, guideline, protocol or other similar criterion on which the appeal decision was based, d. The clinical rationale, which includes an understandable summary of the medical criteria, benefit provision, guideline or protocol used to make the determination, e. A statement that the specific medical criteria or benefit provision used in making the determination will be provided upon request, f. The titles and qualifications of the individual(s) participating in the appeal review, 6. A statement and copies of all documents relevant to the member s appeal will be provided upon request. If the appeal decision maintains the original adverse decision the written notification will also include: a. A description of the procedure for requesting an external independent review, b. The time frame for submission of an external appeal request, c. The member s right to designate someone to act on his/her behalf, d. Language confirming the external reviewer s decision is binding, e. a statement that benefits beyond those included in the benefit certificate are not eligible for external review and f. A statement that there is no cost to the member should they request external review. g. A description of further appeal rights if applicable. BCBSIL Provider Manual Rev 8/14 13

14 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 8 of 27 h. The member may be eligible to receive their adverse determination notification in Spanish, Tagalog, Chinese or Navajo if applicable. (See Attachment) Note: If the appeal decision maintains the original adverse decision and the appeal request is from a member of an ACA-regulated ASO Group who has not hired BCBSIL to handle its external review process, then the written notification will be customized to meet the needs of the Group. The appropriate applications are updated and the complete file is maintained in an electronic format within the BCBSIL corporate electronic record storage system the (Enterprise Appeal Application). The complete file can also be maintained in a secure area including but not limited to a locked cabinet Independent External Review 1. Following an adverse determination for a pre-service, concurrent or post-service clinical appeal, members of ASO Groups who have not elected to voluntarily comply with the Illinois External Review Act may request an external independent review. The Member may request an external independent review directly from an Independent Review Organization, (IRO). a. Requests for external reviews that BCBSIL receives from Members of ASO Groups who have not hired BCBSIL to handle its external review process, will be referred to the Group or the Group s designee. b. Requests for external reviews that BCBSIL receives from Members of ASO Groups who have elected to follow the Federal external review process will be handled in accordance with the Federal External Review Process, as currently appearing in federal legislation and/or regulation. The appropriate applications are updated and the complete file is maintained in an electronic format within the BCBSIL corporate electronic record storage system the (Enterprise Appeal Application). Documentation 1. BCBSIL maintains records for each appeal that includes: a. The name of the patient, provider, and/or facility b. Copies of all correspondence from the patient, provider or facility rendering service and BCBSIL regarding the appeal c. Dates of appeal reviews, documentation of actions taken and final resolution d. Name and credentials of the clinical peer reviewer BCBSIL Provider Manual Rev 8/14 14

15 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 9 of 27 Reviewed: 12/1/13 BCBSIL Provider Manual Rev 8/14 15

16 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 10 of 27 Reviewed: 12/1/13 BCBSIL Provider Manual Rev 8/14 16

17 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 11 of 27 Clinical Approval Member Level 1 UGF $DATE $TO_FIRST_NAME $TO_LAST_NAME $TO_ADDRESS_LINE_1_2 $TO_CITY, $TO_STATE $TO_ZIP Dear $TO_FIRST_NAME $TO_LAST_NAME: This letter is in response to your request for an appeal of the denial of the treatment or service(s) described below. Blue Cross and Blue Shield of IL (BCBSIL) has conducted a first level appeal. We have approved your request for payment. Name: $MEMBER_FIRST_NAME Reference Number: $APPEALS_ID $MEMBER_LAST_NAME Claim(s) #: Date of Service: $CLAIM_BEGIN_DATE $CLAIM_ADJUSTMENT_NUMBERS $CLAIM_END_DATE Total Claim Amount: $TOTAL_AMOUNT_RELATIVE_TO_THE_APPEAL Provider Name: $PROVIDER_FIRST_NAME $PROVIDER_LAST_NAME Facility: $FACILITY_NAME $FACILITY_CONTACT_NAME Denial Code(s): $CLAIM_DENIAL_REASON_CODE Treatment and diagnosis codes available upon request. Reason for Denial: $CLAIM_DENIAL_REASON_DESCRIPTION A physician who specializes in $PHYSICIAN_SPECIALIST and who had no involvement in the original denial reviewed your request and the available clinical information. Based on this review, we have approved your request for the following reason: $INTERNAL_NOTES. You can request a copy free of charge of the actual benefit provision, guideline, protocol or other similar criterion that we relied upon. You may also obtain copies of all documents relevant to the appeal, including any new or additional evidence. In addition, the names of all reviewers of your appeal may be made available to you upon request. Note that actual availability of benefits is subject to the member s eligibility and other terms, conditions, limitations, provider eligibility and exclusions of the member s health care benefit plan. For questions or BCBSIL Provider Manual Rev 8/14 17

18 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 12 of 27 more details, please call us at the Customer Service number listed on your member ID card or refer to your Summary Plan Description or benefit booklet. For Additional Assistance For questions about your rights, this notice, or for assistance contact Employee Benefits Security Administration at EBSA (3272). For questions about your rights, this letter, or for assistance, you can contact a consumer assistance program or ombudsman at: Illinois Illinois Department of Insurance 100 Randolph Street 9th Floor Chicago, Illinois Phone: You may receive your adverse determination and this notice in a language listed below. In addition, you may call us to receive assistance in these languages. If you have additional questions, please contact me at $USER_PHONE_NUMBER. Sincerely, Image:USER_SIGNATURE $USER_FIRST_NAME $USER_LAST_NAME $USER_JOB_TITLE Appeals Department Consumer Services Management $CC $ATTACHMENT $ATTACHMENT_LIST Reviewed 12/1/13 BCBSIL Provider Manual Rev 8/14 18

19 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 13 of 27 Clinical Approval Member NGF Level 1 $DATE $TO_FIRST_NAME $TO_LAST_NAME $TO_ADDRESS_LINE_1_2 $TO_CITY, $TO_STATE $TO_ZIP Dear $TO_FIRST_NAME $TO_LAST_NAME: This letter is in response to your request for an appeal of the denial of the treatment or service(s) described below. Blue Cross and Blue Shield of IL (BCBSIL) has conducted a first level appeal. We have approved your request for payment. Name: $MEMBER_FIRST_NAME Reference Number: $APPEALS_ID $MEMBER_LAST_NAME Claim(s) #: Date of Service: $CLAIM_BEGIN_DATE $CLAIM_ADJUSTMENT_NUMBERS $CLAIM_END_DATE Total Claim Amount: $TOTAL_AMOUNT_RELATIVE_TO_THE_APPEAL Provider Name: $PROVIDER_FIRST_NAME $PROVIDER_LAST_NAME Facility: $FACILITY_NAME $FACILITY_CONTACT_NAME Denial Code(s): $CLAIM_DENIAL_REASON_CODE Treatment and diagnosis codes available upon request. Reason for Denial: $CLAIM_DENIAL_REASON_DESCRIPTION A physician who specializes in $PHYSICIAN_SPECIALIST and who had no involvement in the original denial reviewed your request and the available clinical information. Based on this review, we have approved your request for the following reason: $INTERNAL_NOTES. You can request a copy free of charge of the actual benefit provision, guideline, protocol or other similar criterion that we relied upon. You may also obtain copies of all documents relevant to the appeal, including any new or additional evidence. In addition, the names of all reviewers of your appeal may be made available to you upon request. Note that actual availability of benefits is subject to the member s eligibility and other terms, conditions, limitations, provider eligibility and exclusions of the member s health care benefit plan. For questions or more details, please call us at the Customer Service number listed on your member ID card or refer to your Summary Plan Description or benefit booklet. BCBSIL Provider Manual Rev 8/14 19

20 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 14 of 27 For Additional Assistance For questions about your rights, this notice, or for assistance contact Employee Benefits Security Administration at EBSA (3272). For questions about your rights, this letter, or for assistance, you can contact a consumer assistance program or ombudsman at: Illinois Illinois Department of Insurance 100 Randolph Street 9th Floor Chicago, Illinois Phone: You may receive your adverse determination and this notice in a language listed below. In addition, you may call us to receive assistance in these languages. If you have additional questions, please contact me at $USER_PHONE_NUMBER. Sincerely, Image:USER_SIGNATURE $USER_FIRST_NAME $USER_LAST_NAME $USER_JOB_TITLE Appeals Department Consumer Services Management $CC $ATTACHMENT $ATTACHMENT_LIST Reviewed 12/1/13 BCBSIL Provider Manual Rev 8/14 20

21 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 15 of 27 Clinical Approval Member NGF Level 2 $DATE $TO_FIRST_NAME $TO_LAST_NAME $TO_ADDRESS_LINE_1_2 $TO_CITY, $TO_STATE $TO_ZIP Dear $TO_FIRST_NAME $TO_LAST_NAME: This letter is in response to your request for an appeal of the denial of the treatment or service(s) described below. Blue Cross and Blue Shield of IL (BCBSIL) has conducted a second level appeal. We have approved your request for payment. Name: $MEMBER_FIRST_NAME Reference Number: $APPEALS_ID $MEMBER_LAST_NAME Claim(s) #: Date of Service: $CLAIM_BEGIN_DATE $CLAIM_ADJUSTMENT_NUMBERS $CLAIM_END_DATE Total Claim Amount: $TOTAL_AMOUNT_RELATIVE_TO_THE_APPEAL Provider Name: $PROVIDER_FIRST_NAME $PROVIDER_LAST_NAME Facility: $FACILITY_NAME $FACILITY_CONTACT_NAME Denial Code(s): $CLAIM_DENIAL_REASON_CODE Treatment and diagnosis codes available upon request. Reason for Denial: $CLAIM_DENIAL_REASON_DESCRIPTION A physician who specializes in $PHYSICIAN_SPECIALIST and who had no involvement in the original denial reviewed your request and the available clinical information. Based on this review, we have approved your request for the following reason: $INTERNAL_NOTES. You can request a copy free of charge of the actual benefit provision, guideline, protocol or other similar criterion that we relied upon. You may also obtain copies of all documents relevant to the appeal, including any new or additional evidence. In addition, the names of all reviewers of your appeal may be made available to you upon request. Note that actual availability of benefits is subject to the member s eligibility and other terms, conditions, limitations, provider eligibility and exclusions of the member s health care benefit plan. For questions or more details, please call us at the Customer Service number listed on your member ID card or refer to your Summary Plan Description or benefit booklet. BCBSIL Provider Manual Rev 8/14 21

22 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 16 of 27 For Additional Assistance For questions about your rights, this notice, or for assistance contact Employee Benefits Security Administration at EBSA (3272). For questions about your rights, this letter, or for assistance, you can contact a consumer assistance program or ombudsman at: Illinois Illinois Department of Insurance 100 Randolph Street 9th Floor Chicago, Illinois Phone: You may receive your adverse determination and this notice in a language listed below. In addition, you may call us to receive assistance in these languages. If you have additional questions, please contact me at $USER_PHONE_NUMBER. Sincerely, Image:USER_SIGNATURE $USER_FIRST_NAME $USER_LAST_NAME $USER_JOB_TITLE Appeals Department Consumer Services Management $CC $ATTACHMENT $ATTACHMENT_LIST Reviewed 12/1/13 BCBSIL Provider Manual Rev 8/14 22

23 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 17 of 27 Clinical Approval Member NGF Level 3 $DATE $TO_FIRST_NAME $TO_LAST_NAME $TO_ADDRESS_LINE_1_2 $TO_CITY, $TO_STATE $TO_ZIP Dear $TO_FIRST_NAME $TO_LAST_NAME: This letter is in response to your request for an appeal of the denial of the treatment or service(s) described below. Blue Cross and Blue Shield of IL (BCBSIL) has conducted a third level appeal. We have approved your request for payment. Name: $MEMBER_FIRST_NAME Reference Number: $APPEALS_ID $MEMBER_LAST_NAME Claim(s) #: Date of Service: $CLAIM_BEGIN_DATE $CLAIM_ADJUSTMENT_NUMBERS $CLAIM_END_DATE Total Claim Amount: $TOTAL_AMOUNT_RELATIVE_TO_THE_APPEAL Provider Name: $PROVIDER_FIRST_NAME $PROVIDER_LAST_NAME Facility: $FACILITY_NAME $FACILITY_CONTACT_NAME Denial Code(s): $CLAIM_DENIAL_REASON_CODE Treatment and diagnosis codes available upon request. Reason for Denial: $CLAIM_DENIAL_REASON_DESCRIPTION A physician who specializes in $PHYSICIAN_SPECIALIST and who had no involvement in the original denial reviewed your request and the available clinical information. Based on this review, we have approved your request for the following reason: $INTERNAL_NOTES. You can request a copy free of charge of the actual benefit provision, guideline, protocol or other similar criterion that we relied upon. You may also obtain copies of all documents relevant to the appeal, including any new or additional evidence. In addition, the names of all reviewers of your appeal may be made available to you upon request. Note that actual availability of benefits is subject to the member s eligibility and other terms, conditions, limitations, provider eligibility and exclusions of the member s health care benefit plan. For questions or more details, please call us at the Customer Service number listed on your member ID card or refer to your Summary Plan Description or benefit booklet. BCBSIL Provider Manual Rev 8/14 23

24 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 18 of 27 For Additional Assistance For questions about your rights, this notice, or for assistance contact Employee Benefits Security Administration at EBSA (3272). For questions about your rights, this letter, or for assistance, you can contact a consumer assistance program or ombudsman at: Illinois Illinois Department of Insurance 100 Randolph Street 9th Floor Chicago, Illinois Phone: You may receive your adverse determination and this notice in a language listed below. In addition, you may call us to receive assistance in these languages. If you have additional questions, please contact me at $USER_PHONE_NUMBER. Sincerely, Image:USER_SIGNATURE $USER_FIRST_NAME $USER_LAST_NAME $USER_JOB_TITLE Appeals Department Consumer Services Management $CC $ATTACHMENT $ATTACHMENT_LIST Reviewed 12/1/13 BCBSIL Provider Manual Rev 8/14 24

25 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 19 of 27 Clinical Member Denial Level 1 UGF $DATE $TO_FIRST_NAME $TO_LAST_NAME $TO_ADDRESS_LINE_1_2 $TO_CITY, $TO_STATE $TO_ZIP Dear $TO_FIRST_NAME $TO_LAST_NAME: This letter is in response to your request for an appeal of the denial of the treatment or service(s) described below. Blue Cross and Blue Shield of IL (BCBSIL) has conducted a first level appeal as required by your employer. We have denied your request for payment. Name: $MEMBER_FIRST_NAME Reference Number: $APPEALS_ID $MEMBER_LAST_NAME Claim(s) #: Date of Service: $CLAIM_BEGIN_DATE $CLAIM_ADJUSTMENT_NUMBERS $CLAIM_END_DATE Total Claim Amount: $TOTAL_AMOUNT_RELATIVE_TO_THE_APPEAL Provider Name: $PROVIDER_FIRST_NAME $PROVIDER_LAST_NAME Facility: $FACILITY_NAME $FACILITY_CONTACT_NAME Denial Code(s): $CLAIM_DENIAL_REASON_CODE Treatment and diagnosis codes available upon request. Reason for Denial: $CLAIM_DENIAL_REASON_DESCRIPTION Rationale A physician who specializes in $PHYSICIAN_SPECIALIST and who had no involvement in the original denial reviewed your request and the available clinical information. Based on this review, we have denied your request due to: $INTERNAL_NOTES You can request a copy free of charge of the actual benefit provision, guideline, protocol or other similar criterion that we relied upon. You may also obtain copies of all documents relevant to the appeal, including any new or additional evidence. In addition, the names of all reviewers of your appeal may be made available to you upon request. BCBSIL Provider Manual Rev 8/14 25

26 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 20 of 27 Note that actual availability of benefits is subject to the member s eligibility and other terms, conditions, limitations, provider eligibility and exclusions of the member s health care benefit plan. For questions or more details, please call us at the Customer Service number listed on your member ID card or refer to your Summary Plan Description or benefit booklet. Next Steps Your employer plan specified the levels of appeals available to you. Based on our contract with your employer, the internal appeal process is exhausted. If we have continued to deny partial or full payment or coverage, you have the right to bring a civil under section 502(a) of ERISA. action This completes the internal review process. However you may be entitled to request an external review by an Independent Review Organization (IRO). The review is conducted at no cost to you. To request an external review, you must complete and return the enclosed Request for External Review form within four months of the date of this letter. For Additional Assistance For questions about your rights, this notice, or for assistance contact Employee Benefits Security Administration at EBSA (3272). For questions about your rights, this letter, or for assistance, you can contact a consumer assistance program or ombudsman at: Illinois Illinois Department of Insurance 100 Randolph Street 9th Floor Chicago, Illinois Phone: You may receive your adverse determination and this notice in a language listed below. In addition, you may call us to receive assistance in these languages. If you have additional questions, please contact me at $USER_PHONE_NUMBER. Sincerely, Image:USER_SIGNATURE BCBSIL Provider Manual Rev 8/14 26

27 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 21 of 27 $USER_FIRST_NAME $USER_LAST_NAME $USER_JOB_TITLE Appeals Department Consumer Services Management $CC $ATTACHMENT $ATTACHMENT_LIST Reviewed 12/1/13 BCBSIL Provider Manual Rev 8/14 27

28 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 22 of 27 Clinical Member Denial Level 2 UGF $DATE $TO_FIRST_NAME $TO_LAST_NAME $TO_ADDRESS_LINE_1_2 $TO_CITY, $TO_STATE $TO_ZIP Dear $TO_FIRST_NAME $TO_LAST_NAME: This letter is in response to your request for an appeal of the denial of the treatment or service(s) described below. Blue Cross and Blue Shield of IL (BCBSIL) has conducted a second level appeal as required by your employer. We have denied your request for payment. Name: $MEMBER_FIRST_NAME Reference Number: $APPEALS_ID $MEMBER_LAST_NAME Claim(s) #: Date of Service: $CLAIM_BEGIN_DATE $CLAIM_ADJUSTMENT_NUMBERS $CLAIM_END_DATE Total Claim Amount: $TOTAL_AMOUNT_RELATIVE_TO_THE_APPEAL Provider Name: $PROVIDER_FIRST_NAME $PROVIDER_LAST_NAME Facility: $FACILITY_NAME $FACILITY_CONTACT_NAME Denial Code(s): $CLAIM_DENIAL_REASON_CODE Treatment and diagnosis codes available upon request. Reason for Denial: $CLAIM_DENIAL_REASON_DESCRIPTION Rationale A physician who specializes in $PHYSICIAN_SPECIALIST and who had no involvement in the original denial reviewed your request and the available clinical information. Based on this review, we have denied your request due to: $INTERNAL_NOTES You can request a copy free of charge of the actual benefit provision, guideline, protocol or other similar criterion that we relied upon. You may also obtain copies of all documents relevant to the appeal, including any new or additional evidence. In addition, the names of all reviewers of your appeal may be made available to you upon request. BCBSIL Provider Manual Rev 8/14 28

29 Member Clinical Appeal & External Independent Review: ASO Groups Not Voluntarily Complying with the IL External Review Act Page 23 of 27 Note that actual availability of benefits is subject to the member s eligibility and other terms, conditions, limitations, provider eligibility and exclusions of the member s health care benefit plan. For questions or more details, please call us at the Customer Service number listed on your member ID card or refer to your Summary Plan Description or benefit booklet. Next Steps Your employer plan specified the levels of appeals available to you. Based on our contract with your employer, the internal appeal process is exhausted. If we have continued to deny partial or full payment or coverage, you have the right to bring a civil action under section 502(a) of ERISA. This completes the internal review process. However you may be entitled to request an external review by an Independent Review Organization (IRO). The review is conducted at no cost to you. To request an external review, you must complete and return the enclosed Request for External Review form within four months of the date of this letter. For Additional Assistance For questions about your rights, this notice, or for assistance contact Employee Benefits Security Administration at EBSA (3272). For questions about your rights, this letter, or for assistance, you can contact a consumer assistance program or ombudsman at: Illinois Illinois Department of Insurance 100 Randolph Street 9th Floor Chicago, Illinois Phone: You may receive your adverse determination and this notice in a language listed below. In addition, you may call us to receive assistance in these languages. If you have additional questions, please contact me at $USER_PHONE_NUMBER. Sincerely, Image:USER_SIGNATURE BCBSIL Provider Manual Rev 8/14 29

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