MEDICAL MANAGEMENT OVERVIEW MEDICAL NECESSITY CRITERIA RESPONSIBILITY FOR UTILIZATION REVIEWS MEDICAL DIRECTOR AVAILABILITY

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1 4 MEDICAL MANAGEMENT OVERVIEW Our medical management philosophy and approach focus on providing both high quality and cost-effective healthcare services to our members. Our Medical Management Department is designed to align our goals of member service, effective medical management, and member and provider satisfaction. The Medical Management Department shares this commitment by: Making utilization management decisions based only on the appropriateness of care and service and existence of coverage Not rewarding our medical staff or other people who perform medical management functions for denials of coverage for medical care and services Having no financial incentives to encourage decisions that could result in underutilization RESPONSIBILITY FOR UTILIZATION REVIEWS Empire s Medical Management Department performs the utilization reviews for most of Empire s products. However, Empire delegates this responsibility to a third-party vendor with respect to certain services (e.g., behavioral health). In addition, certain Empire group customers have chosen to have a third-party vendor perform utilization review for their hospital services. To the extent any third-party vendors perform utilization review on behalf of Empire or its group customers, Empire obligates its own directly contracted vendors, and uses best efforts to contractually bind those vendors directly contracted by the group customer, to render medical necessity determinations in a manner consistent with the terms of Empire s participation agreements and policies and procedures, and in accordance with all applicable federal and state statutes and regulations. MEDICAL NECESSITY CRITERIA Empire s Medical Management nurses use evidencebased clinical criteria to assess the medical necessity and appropriateness of care and services. Generally, Empire utilizes Milliman s CarePC criteria as a guideline for medical necessity decisions, although CMS Medicare Guidelines are used for skilled nursing facility and inpatient rehabilitation services. Empire reserves the right to adopt different criteria at any time. Empire may also utilize internally developed criteria as a guideline to determine medical necessity when CarePC criteria are inappropriate. Copies of these criteria are made available to providers by calling Medical Management at , Monday Friday, 8:30 a.m. 5:00 p.m. MEDICAL DIRECTOR AVAILABILITY Empire s medical directors are available to discuss medical necessity denial decisions with physicians. To speak to a medical director, refer to the denial notification. It includes information regarding how to contact the medical director. PRECERTIFICATION AND NOTIFICATION REQUIREMENTS The list of admissions and services found on the Precertification Guide in Chapter One of this Sourcebook require precertification through Empire Medical Management or the designated vendor. For Senior Plan Direct, precertification is required even page 22

2 when we are the secondary insurer. Not all managed indemnity products require precertification for all of the services listed in the Precertification Guide. To help ensure that the patient receives the highest level of benefits, contact Medical Management by calling the telephone number on the back of the patient s identification card. Notification Policy We require notification of all inpatient emergency admissions within 48 hours of the admission. To support this requirement, our Medical Management telephone lines are available outside of normal business hours, 24 hours a day/7 days a week, through our Nurse Call Center, Talk-2-RN ( ). You may also notify us of an emergency admission by submitting the information through Empire s Facility Online Services. If you are not yet registered to use this service, please go to Empire s website, and click on the Facilities tab. Doing so will provide a fast and dependable way to notify Empire of admissions without having to make a telephone call. Empire s Facility Online Services is available 24/7, with the exception of brief periods when the website undergoes system maintenance. If you prefer to call Medical Management during nonbusiness hours, an option for notification of emergency admissions will be provided. The process is simple and the call will be handled by medical management staff. For HMO-Based Products If Medical Management is not notified within the required time frames, we will deny payment for the days of service prior to the date of notification. The Medical Management Department will conduct a medical review based on our Medical Management standards only from the date that notification of the hospital admission is received, if the patient is still in the hospital. If the patient has already been discharged at the time of the notification, Medical Management will not review the admission and the claim will be denied for lack of notification. For PPO, EPO and Indemnity Products Except as expressly stated in the Precertification Guide the responsibility of precertification for PPO, EPO and Indemnity products is placed on the member, based on the terms of the member s contract. If the member fails to notify Medical Management for a service requiring precertification, the service will either be denied or the member will be subject to a monetary penalty specific to his or her contract. To avoid subjecting the member to full or partial payment responsibility in cases where you are aware that the member s precertification requirements have not been followed, you may choose to contact us on behalf of the member. For Participating Hospitals that Have Executed the GNYHA Amendment Empire will not deny payment for medically necessary services based on a hospital s failure to comply with Empire s utilization review procedures, as long as the hospital complies with the notification requirements on an average of 93% of the time. If Medical Management is not notified within the required time frames, we will pay the claim upon receipt, but may initiate a retrospective medical necessity review. If we subsequently deny the claim for lack of medical necessity, you will have the right to appeal. Precertification Review Process When you call us at the toll-free number listed on the back of the member s identification card, the service representative will request the following information: Member s and/or patient s identification number Patient s name, address and date of birth Scheduled/actual date of admission Type of admission (scheduled or emergent) Attending physician s name and telephone number Primary care physician s (PCP) name and telephone number (where applicable) Once this information is obtained, your call will be transferred to a Medical Management Registered Nurse, who will review each request for medical appropriateness of services and setting. This review is based on nationally recognized criteria. If the criteria are met, our nurse documents clinical data on our Medical Management System and authorizes the requested covered service. Precertification approval letters are mailed to you, the member, the PCP, and the attending physician within one business day of the decision. If our nurse determines that criteria are not met, or there is insufficient information to complete a review, the requested service will be referred to one of our Medical Directors. The Medical Director will review the information, and the attending physician may be contacted to obtain more clinical data on the case. page 23

3 If the Medical Director does not approve the prospective admission, you, the member, the PCP, and/or the attending physician are notified of the denial in writing. Once a covered service has been precertified, we will not reverse our medical necessity decision unless all of the following circumstances are present: 1. Relevant medical information presented upon retrospective review is materially different from the information presenting during precertification; 2. The information existed at the time of precertification but was not made available; 3. Empire, or its delegate, was not aware of the existence of the information at the time of precertification and 4. The treatment, service or procedure would not have been authorized if the information were available at the time of precertification. Empire as Secondary Payor If Empire is the secondary payor, it will not require the hospital or the member to obtain precertification from Empire, and will not deny or reduce amounts that would otherwise be owed because a provider or subscriber did not comply with its administrative or utilization review requirements, including notification, precertification, or concurrent review. However, Empire will not be bound by the primary payor s decisions concerning the medical necessity of a service. CONCURRENT REVIEW PROCESS TELEPHONIC AND ON-SITE Once we have approved an initial length of stay, you must continue to work with the Medical Management Department for approval of additional days. It is your facility s responsibility to provide all information to your telephonic or on-site nurse. At Empire, we use facility-based Medical Management nurses called On-Site Case Managers (OCMs) to conduct On-Site Concurrent Reviews at certain participating facilities. The goal of our telephonic and on-site nurses is to effect a treatment plan that provides optimum care in a cost-effective manner and results in the earliest possible discharge without jeopardizing the full recovery of the patient. If your facility is reimbursed as a DRG/Case Rate, you will be responsible for providing admission review and discharge planning information only. If there is a high or low trim point, you may be asked to provide additional clinical information as well. You will also be responsible for providing the patient s discharge date to Empire. Our case managers will be contacting your utilization review staff to gather clinical information to assess medical necessity for our members. For facilities with an OCM, the CM will visit you to review pertinent medical records as often as is necessary. All of our nurses utilize clinical information from the medical record, the hospital staff, attending physician, Clinical Practice Guidelines, and Medical Policies to coordinate a medically effective and efficient transition through the case management process. If Empire s nurses cannot determine medical necessity for any day of confinement requested by the attending physician, or if the nurse questions the necessity or cost-effectiveness of treatment, he/she will discuss the course of treatment with your case manager and/or the attending physician. If after this discussion the nurse still cannot certify a day or does not concur with the proposed plan of care, he/she will refer the case to a Medical Director. A Medical Director will review the information provided and may discuss the case with the attending physician or your medical director. If a determination is made that treatment or confinement is not medically necessary, the attending physician and the patient or patient representative will be notified immediately of the decision not to certify. On-Site Case Manager (OCM) Rules and Regulations Our OCM will comply with your Utilization Review Committee s facility utilization review protocols (e.g., sign in, sign out, proper identification, dress code, State/Federal rules and regulations, etc.). The OCM should have access to all units within your facility in which an Empire patient may be staying. The OCM will conduct on-site reviews during facility designated hours. Acceptable hours are Monday Friday, 8:00 a.m. 5:30 p.m. or any other variation of similar workday time frames. Empire does have a Case Manager and Medical Director available after regular business hours and on weekends through its Nurse Call Center. page 24

4 The OCM should have access to all of the patient s current and relevant past charts. Adequate time will be given for the OCM to conduct the on-site process. You will provide room numbers for our patients to the OCM as needed by means of a daily census, if applicable. OCMs should have access to adequate workspace including desks, phones, fax, copy machines, and a digital or analog line to utilize their laptop to gain access to our Medical Management Systems. OCMs will be able to speak with your personnel (e.g., physicians, discharge planners, social workers, nursing staff, Utilization Review staff). When agreed upon by the facility, OCMs should have authority to directly interact with patients and their families to discuss discharge planning and/or enrollment in our Disease Management Programs, such as Asthma or CHF. Our supervisors/managers should have the ability to accompany OCMs periodically for monitoring purposes. OCMs will give appropriate notice, as requested by the facility, for Medical Records to have charts available for retrospective review. Telephonic or fax review may be alternated with or substituted for on-site review in cases where an on-site visit is not feasible. The OCM should develop a rapport with your staff during his/her on-site visits, which will make telephonic or fax review more effective. LAST APPROVED DAY (LAD) REPORT To help you better prioritize the management of your utilization review resources, we produce a Last Approved Day (LAD) Report faxed to your Utilization Review department. This report is faxed by 7:00 a.m., Monday Sunday to assist in the identification of Empire patients who require additional clinical information to continue their hospital stay. This report covers patients participating in our managed care products: HMO, PPO, EPO, POS, Senior Plan Direct, Healthy New York, Child Health Plus, and Managed Indemnity members. This report will not list members who are managed by third-party utilization vendors. You will need to contact the specific third-party utilization management vendor directly. The report s format allows easy identification of patient s status in relation to our Medical Management decisions from the previous day, current day, and the next review date. The report will reflect information received in our Medical Management System by end of business of the previous day. The column marked Next Review Date will identify those patients for whom additional clinical information is required to continue authorization for the hospital stay. This information must be communicated to our Medical Management Department via fax or phone before 12 p.m. (noon) of the day indicated in the next review date column or as soon as reasonably possible. If information needs to be communicated after 5 p.m., our 24-hour Nurse Call Center is available nights, weekends and holidays at (select option 9). If any of the information contained in the report is perceived to be incorrect, please contact our Nurse Case Manager at the toll-free number indicated in the column specific to that patient on the report. The hospital staff should amend the LAD report with a Discharge Date indicating actual date of discharge so that the Covered Person can be removed from the LAD report and included in the Discharge Summary Report faxed separately. The hospital will fax the marked LAD report to Empire at The hospital shall use good faith efforts to contact the admitting physician to obtain a discharge order when appropriate and Empire shall reasonably cooperate with such efforts. An indication in the LAD report that a case has been Certified means that Empire has determined the services described are medically necessary for that date of service, based on the information provided. An indication of DRG means that Empire has determined the services described are medically necessary and that the case rate is appropriate. Coverage for a particular date of service is NOT certified for any Covered Person not included on the LAD report for that date. It is the hospital s responsibility to notify Empire of any Covered Persons not included on the LAD report. If authorization is denied, the denial will be indicated on the LAD report. In addition, Empire will provide a separate written notice of determination, consistent with applicable legal requirements. page 25

5 DELAY IN SERVICE DENIALS If an Empire member has his or her inpatient hospital stay extended as a result of an unwarranted delay in the provision of hospital services due to the unavailability of any hospital equipment, personnel, facilities or test results, we will not reimburse you for the additional bed day(s). Some examples of service delays are equipment failure, operating room scheduling backlog, and unavailable test results. Coverage denials based on the fact that there was, in our judgment, an unnecessary delay in providing a service do not involve a medical necessity determination. They are, therefore, not subject to appeal under our Medical Management Reconsideration and Appeals Process. However, the facility or the physician may file a grievance under our grievance procedure (see Chapter 5 of this Sourcebook). RETROSPECTIVE REVIEW OF EMPIRE CLAIMS In certain circumstances, claims will be reviewed retrospectively to determine medical necessity. Depending on the terms of the hospital s participation agreement with Empire, this review may occur prior to payment or after payment. The hospital must provide, in a timely manner, those medical records requested by Empire to enable Empire to make a decision. Empire will provide notice of its determination within the time frames established by applicable statute, regulation or contractual provision. Hospitals that Have Executed the GNYHA Amendment If you fail to submit medical records for a retrospective review within 50 business days of Empire s request, resulting in a denial, you will NOT automatically have the right to appeal. In those circumstances, you would first have to demonstrate, through Empire s grievance process, that you were not at fault for the delay (e.g., you can prove that you never received the request, or that Empire received the requested records within the applicable time frame). If successful, Empire would conduct a medical necessity review of the case. Otherwise, the claim will remain denied and you may not bill the member. DISCHARGE PLANNING Discharge planning is part of the entire healthcare continuum. For this reason, it is initiated as soon as possible after the patient is admitted, or ideally, at the time of precertification. Discharge planning requires anticipating and/or coordinating resources for ongoing care. The role of the case manager as it pertains to the discharge planning is to: Identify opportunities to improve healthcare efficiency (from quality and/or cost standpoint) Discuss the plan of care with the patient s physician Refer the treatment plan to our Medical Director for additional review whenever indicated Identify strategies for more cost-effective use of patient healthcare resources, consistent with quality care in the most appropriate setting Identify patients for additional case management opportunities by reviewing benefit options and discharge plans with the potential for alternative levels of care BEHAVIORAL HEALTHCARE MANAGEMENT Magellan Behavioral Health is the behavioral health and substance abuse utilization review agent for most of Empire s business, although some employer groups have contracted directly with other vendors. Once you have determined that your patient is an Empire member and in need of behavioral health treatment, please call the number listed on the back of the member s identification card for precertification. Representatives are available 24 hours a day, 7 days a week. The behavioral healthcare management vendor listed on the member s identification card, not the Medical Management Department, should be contacted for precertification of behavioral healthcare services. The program coordinates the following case management functions: Paper referrals Fax authorization for outpatient treatment requests For inpatient mental healthcare, partial hospital programs, outpatient mental healthcare, inpatient alcohol and substance abuse care, and outpatient alcohol and substance abuse care, our program manages the following: page 26

6 Precertification Concurrent review Retrospective review Discharge planning You are responsible for contacting the behavioral healthcare management vendor if the patient is an HMO member. If the patient is a PPO Member, he/she is responsible for calling. For members managed by Magellan Behavioral Health, call , 24 hours a day, 7 days a week. For members managed by other behavioral healthcare vendors, please call the number indicated on the member s identification card. In emergency situations, you (on behalf of the HMO members) or your PPO patient must call the program within 24 hours or as soon as reasonably possible after an admission. page 27