Upper Peninsula Health Plan MIHealth Link. Utilization Management

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1 Upper Peninsula Health Plan MIHealth Link 2014

2 Continuity of Care UPHP must maintain a member s current providers and amount, scope, and duration of services at the time of enrollment. This includes prescription drugs and providers which are not part of UPHP s network. UPHP can transition members to in-plan services following requirements based on the service and population.

3 Continuity of Care For members who are receiving services from the Habilitation Supports Waiver and/or the Specialty Services and Supports Program through the PIHP (NorthCare) UPHP must: Allow member to maintain the current provider at the time of enrollment for 180 calendar days. Honor existing plans of care and prior authorizations until the authorization ends or 180 days from enrollment whichever is sooner

4 Continuity of Care For all other members UPHP must: Maintain current provider at the time of enrollment for 90 calendar days. Honor existing plans of care and prior authorizations until the authorization ends or 180 calendar days from enrollment, whichever is sooner. Allow members to remain at Medicaid Nursing facilities through a contract with UPHP or via single case agreements or an out-of-network basis for the duration of the Demonstration or until the enrollee chooses to relocate.

5 UPHP MIHealth Link- UPHP provides healthcare services to MI Health Link members as a plan of Medicare and Medicaid-covered benefits. Services are to be directed by an in-plan Primary Care Provider (PCP) or specialist Services are to be provided within the UPHP network when available and must be medically necessary. Items and services unavailable in-plan are made available to members following the UPHP out-of-plan referral criteria and when prior authorization is obtained. Members have the right to self-refer to in-network services if the provider does not require referral from PCP or other specialist.

6 UPHP allows members to have a second opinion at no cost to them from: In-plan providers Out-of-plan providers as long as the member has seen an in-plan provider and prior authorization is obtained prior to seeing the out-of-network provider

7 Services not requiring Prior Authorization: Emergency and post-stabilization services which includes emergency behavioral health care and urgent care. Family planning services Out-of-area renal dialysis

8 Prior Authorization is required for the following services: Out-of-plan services: Practitioner services Facility services Durable medical equipment and supplies Medically necessary weight reduction services Medically necessary reconstructive sugery Hearing aids

9 Prior authorization requirements (cont.) Durable medical equipment/medical supplies Not meeting CMS guidelines CPAP/BiPAP- PA required after 12 week period TENS- PA required after 2 months Pneumatic Compression Devices Hospital beds- semi-electric Powered wheelchairs and accessories Negative pressure wound therapy electrical pumps Powered air floatation bed Nonpowered and powered air overlay for mattress Non powered advanced pressure reducing mattress Closed Loop Control Systems (Artificial Pancreas)

10 Notification Requirements Notification is required in order to receive payment for services, but does not involve the application of clinical criteria for an authorization decision. Notification is required to trigger required Care Management activities on the part of UPHP

11 UPHP Notification Requirements: In-plan and out-of-plan inpatient planned admissions Prior to admission In-plan and out-of-plan urgent/emergent admissions Within one business day of admission In-plan and out-of-plan urgent/emergent observation admission Within one business day of admission Transplant services prior to service Reversal of bariatric surgeries prior to services Skilled nursing facility admissions/swing bed admissions Within one business day of admission

12 UPHP prior authorization process: Provider verifies: Member is currently a UPHP member Service request is for a UPHP Medicare and/or Medicaid covered benefit Service request requires prior authorization or notification Provider submits in writing by fax (preferred), phone or mail: Appropriate prior authorization/notification request form. UPHP forms are available from Customer Service or UPHP Web site at Clinical information to support the request as indicated on the form

13 UPHP Decision Timeframes: Pre-Service Non-Urgent- 14 days Urgent/Expedited- 72 hours Urgent/Expedited requests should only be used if the treatment is required to prevent serious deterioration in the member s health or could jeopardize the member s ability to regain maximum function. Requests outside of this definition will be handles as non-urgent.

14 Utilization Criteria UPHP uses written objective criteria based on sound clinical evidence. Appropriate practitioners are involved in developing, adopting, and reviewing criteria. Criteria include: CMS Medicare Managed Care Manual guidelines MDCH Provider Manual UPHP criteria which is reviewed annually by the UPHP Clinical Advisory Committee Criteria is available on UPHP s website under Utilization Management as well as verbally by phone or mailed upon request.

15 Decision Making UPHP Clinical Coordinators- (UM) utilize approved criteria and are applied on a case by case by to incorporate individual needs and to assess the local delivery system for applicable resources or alternatives. Prior Authorization requests that do not meet criteria are forwarded to the Practitioner Reviewer for review and decision.

16 Access to staff There is a UM staff member available during normal business hours (8:00 am to 5:00pm EST Monday through Friday, excluding holidays). A call center operates outside of normal business hours and holidays until 9:00pm EST and can accept standard and expedited requests. Calls after 9:00pm are forwarded to a confidential voic that is checked regularly. Requests may be submitted by fax or by phone

17 How to contact UPHP s department: Toll-free incoming line Hearing or speech impaired members - Michigan Relay Center (TTY) Interpreter Services Dedicated fax line in Clinical Services department UM staff direct phone lines with confidential voice mail address for each individual staff member (upon request) UM staff will accept collect calls

18 Upper Peninsula Health Plan MI Health Link Appeals 2014

19 Appeals UPHP has established policies and procedures to establish an efficient, consistent, systematic, and fair method of managing and resolving MI Health Link member appeals related to utilization management (UM)determinations. UPHP appeal processes and policies are in compliance with regulations and accrediting agency guidelines which includes Centers for Medicare and Medicaid (CMS) and the Michigan Department of Community Health(MDCH).

20 Appeals When UPHP makes an adverse action (denial, reduction, suspension of services), a written statement is provided in easily understandable language containing the reason for the adverse action. UPHP provides a single notice, specific to the service or item type in question, notifying the member of all their Medicare and Medicaid appeal rights. The member will be provided with a copy of any and all applicable appeal forms. UPHP will assist in sending forms to the appropriate review entity. Members or their authorized representatives may file an appeal with any UPHP employee. They have 60 calendar days from the date of notification of an adverse action to file an appeal with UPHP. The appeal can given orally or written to UPHP.

21 Appeals All UPHP MI Health Link members have full access to the Medicare and Medicaid appeals process for benefit appeals. UPHP acknowledges appeals by providing written receipt to member. Member s may have their provider or authorized representative file an appeal on their behalf. UPHP ensures that individuals who make decisions on appeals were not involved in any previous level of review or decision making.

22 Appeals Medicare Benefit Appeals Process Initial appeal to be made to UPHP within 60 days adverse action For standard appeals- decision within 30 calendar days Expedited appeals- decision within 72 hours Timeframe may be extended up to 14 days if there is a need for additional information and UPHP can demonstrate that the delay is in the member s best interest. If UPHP upholds the original decision, UPHP sends automatically to the Independent Review Entity (IRE) for review For standard appeals- decision within 30 calendar days For Expedited appeals- decision within 72 hours Timeframe may be extended up to 14 days.

23 Appeals Medicare Benefit Appeals (continued) If Independent Review Entity (IRE) upholds the UPHP original decision- member can request hearing before Office of Medicare Hearings and Appeals (OMHA) within 60 days of IRE determination Further level of Appeal also available

24 Appeals Medicaid Benefit Appeals Members may appeal to UPHP and/or the Michigan Administrative Hearing System (MAHS) Appeal to UPHP within 60 days of adverse notice Standard Appeal- Decision within 30 calendar days Expedited Appeal- Decision within 72 hours Timeframe may be extended up to 14 days if there is a need for additional information and UPHP can demonstrate that the delay is in the member s best interest. Appeal to MAHS within 90 days of adverse notice Decisions within 90 calendar days of the received request

25 Appeals Medicaid Benefit Appeals (continued) If UPHP upholds the decision on appeal, it will not be auto-forwarded to Michigan Administrative Hearing System (MAHS), but the member may appeal to MAHS if within the 90 days of the adverse notice Member s have the right to request external review with the Michigan Department of Insurance and Financial Services (DIFS) for Medicaid denials (member must go through the UPHP internal appeal process first)

26 Appeals Continuation of Benefits Pending Appeal or State Fair Hearing UPHP must provide continuing benefits for all prior approved non- Part D benefits that are terminated or modified pending internal entity appeals. For appeals filed with MAHS, Covered services will continue for appeals requested within(12) calendar days of the date of the Adverse action notice For external reviews filed with DIFS, Medicaid covered services will continue for requests appealed within twelve (12) calendar days of the adverse action notice Payments will not be recouped based on the outcome of the appeal for services covered during pending Appeals

27 Appeals Questions?