Section 3: Utilization Management, Including Authorization and Notification Requirements
3.1 Overview of BMC HealthNet Plan’s Utilization Management
Utilization Management (UM) is the ongoing process of evaluating requests for coverage by determining the member’s eligibility, and the medical necessity and efficiency of the requested health care service under the terms of the applicable product. The definition of medically necessary services differs among products due to different regulatory definitions applicable to these products. These definitions are in the member benefit documents.
The UM process begins when the Plan’s Office of Clinical Affairs staff receives a request for services and performs a review to evaluate whether the request meets the applicable definitions of covered services and medical necessity. After considering the member’s clinical information, the Plan renders a clinical decision regarding coverage utilizing the Plan’s Medical Policy Guidelines/Criteria. These Guidelines/Criteria are:
- evidence based and scientifically derived if practicable;
- developed in accordance with the standards created and adopted by nationally accredited organizations;
- developed with input from Plan practicing physicians, external specialty consultants and advisory boards as needed;
- developed in accordance with applicable contractual obligations and regulatory requirements;
- applied in a manner that considers the individual clinical circumstances of the member;
- used as a guideline for making medical necessity decisions but is not a substitute for professional clinical judgment; and
- reviewed on an annual basis with input from appropriate actively practicing physicians and other specialists and updated as new treatments, applications and technologies are adopted as generally accepted professional medical practice and approved for implementation by the Utilization Management Committee (UMC) and Quality Improvement Committee (QIC).
The Plan conducts audits to ensure that the application of criteria is performed in a consistent manner.
You may access a copy of the Medical Policy Guidelines/Criteria used by the Plan to render a determination at bmchp.org or by calling the provider line at 888-566-0010. See section 14.3.3.2 of this manual for instructions on how to obtain a log in identification (ID) number and password for the Plan’s website. Additionally, the Medical Policy Guidelines/Criteria are available to providers upon request by calling the Prior Authorization department or by contacting your Provider Relations representative.
Please note that the Plan’s UM program plan requires that qualified licensed health care professionals render or supervise all clinical review decisions. Under certain circumstances, non-clinical staff may authorize requests for coverage based on explicit instructions and coverage guidelines. All utilization review decisions to deny coverage are made by qualified, licensed physicians or other appropriately licensed clinicians with the appropriate clinical expertise, as allowed by law. For example, pharmacy denial decisions are rendered by the Plan’s licensed pharmacists.
A Plan medical director is available to providers by phone to discuss coverage denial determinations based on medical necessity. In addition, as required by applicable law, providers may seek reconsideration of an initial or concurrent denial of coverage decision from a board-certified, actively practicing, clinical peer reviewer in the same or similar specialty as typically manages the medical condition, procedure or treatment under review.
The Plan does not reward practitioners, providers, or employees who perform utilization reviews, including delegated entities, for not authorizing health care services. No one is compensated or provided incentives to encourage denials or limit authorization or to discontinue medically necessary covered services. Denials are based on lack of medical necessity or because a service is not a covered service.
3.2 Utilization Management Vendors
The Plan contracts with the following vendors to perform authorization and utilization management:
- Beacon Health Strategies to manage the Plan’s behavioral health program. Please direct all behavioral health inquiries to Beacon Health Strategies at beaconhealthstrategies.com or call Beacon at 1-866-444-5155.
- Northwood, Inc. (northwoodinc.com) to manage most durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) billed and dispensed by select provider types outlined in section 3.5.1 to contact Northwood:
Phone – 866-802-6471 8:30 a.m. to 5 p.m. EST, Monday through Friday
Fax – Submit a completed Prior Authorization Fax Form to 877-552-6551 - MedSolutions, Inc. to manage non-emergent outpatient radiology services such as:
- MRIs/MRAs,
- CT/CTA
- PET scans
- Nuclear cardiology studies
medsolutionsonline.com.
- Via toll-free calling to MedSolutions at 888-693-3211.
- Via fax: Send a fax with required office notes and previous imaging reports for the patient to 888-693-3210.
3.3 The Plan’s Prior Authorization Department
The Prior Authorization department reviews requests for certain services and products to ensure that members receive medically necessary care at the appropriate level and in the appropriate setting.
The authorization review process includes:
- Verifying member benefits and eligibility, applicable provider network, PCP assignment, and servicing provider‘s participation.
- Documenting service requests and supporting information.
- Evaluating level and location of care and length of stay to ensure that the requested service is medically appropriate for the member’s diagnosis and/or symptom(s).
- Evaluating the requested services using nationally recognized criteria such as InterQual® clinical criteria or the Plan’s internal Medical Policy Guidelines/Criteria. If our prior authorization staff is unable to establish medical necessity using the Plan’s Medical Policy Guidelines/Criteria, the case is directed to a Plan medical director or other qualified, licensed clinician for review and determination.
- Providing alternative coverage options when clinically appropriate.
- Communicating coverage determinations to members and providers.
- Identifying cases that our care management staff should evaluate for more extensive care coordination.
3.4 The Plan’s Acute Care Coordination (ACC) Program
The Acute Care Coordination program’s objective is to provide an interactive process that promotes systems to monitor and improve utilization efficiency and reduce cost while managing the health needs, clinical outcomes and satisfaction of our members. ACC receives notification once members have been admitted to observation or inpatient level of care.
Acute care coordination includes:
- Application of nationally recognized criteria such as InterQual® clinical criteria or the Plan’s internal Medical Policy Guidelines/Criteria for emergent acute inpatient admissions and continued stay as well as preadmission and continued stay in the acute rehabilitation and skilled nursing facility levels of care.
- Coordination of inpatient clinical services in settings that are best suited to the needs of the member.
- Evaluation of care to ensure appropriate use of resources and highest quality of care received
- Development and implementation of alternatives and innovative services that enhance high-quality, cost-effective care.
- Collaborations with state agencies on the management of impacted members as appropriate.
Our Acute Care Coordination (ACC) clinicians perform medical utilization management functions under the direction of a Plan medical director and licensed clinical manager. The staff works to ensure that the level of care during an inpatient stay is appropriate, and works with hospital case managers, discharge planners and attending physicians to facilitate a timely and appropriate transition between levels of care through the following processes:
- Admission review
- Concurrent review
- Review of discharge plan for appropriateness
- Providing Plan benefit information to assist with the planning of post-hospital services
- Coordinate care linkages between provider and the member by identifying members who use hospital-based services and ensuring that there is planned PCP follow-up.
- Identification of members who may benefit from post-hospital care management services and make referrals to our care management staff.
3.4.1 Long-Term Care Review
Our ACC clinicians evaluate the medical necessity of admissions to and continued stay in long-term care facilities and acute rehabilitation facilities using InterQual® clinical criteria. The ACC clinician identifies the purpose, goals, and expected duration of the stay. For inpatient medical rehabilitation programs, the member must be able to actively participate in the treatment program. The ACC staff is responsible for:
- Evaluating the proposed transfer from the acute care setting to the long-term care setting and validating that the level of care is appropriate for the member’s needs and condition(s).
- Notifying the long-term care facility of the availability of the member’s benefits.
- Requesting that the member be screened for admission to the appropriate institution.
- Coordinating the prior authorization process between the Plan and the long-term care facility.
3.5 Plan Authorization Requirements
This section describes prior authorization requirements.
Please note:
- Specific covered services, benefit exclusions and any benefit limitations are outlined in the member benefit documents posted on the member page at bmchp.org.
- The Plan’s Prior Authorization department staff is available 8 a.m. to 5 p.m., Monday through Friday (except holidays).
- The Medical Prior Authorization request form is available in section 15 of this Provider Manual.
- Prior to delivering services, you must check member eligibility on the date of service. You must check the member’s eligibility daily for all inpatient admissions as MassHealth members’ eligibility may change from day to day. See section 8.2 for guidelines and step-by-step instructions on how to determine member eligibility in the Plan. A provider may contact the Provider Services Department at any time to determine member benefits and eligibility, PCP assignment, and provider participation.
- Once we receive a prior authorization request, we provide you with a reference number by telephone or fax in accordance with the timeframes listed in section 4.1.2. The reference number is assigned for tracking purposes and to inform you that we have received the request. The reference number does not guarantee payment. Payment is contingent on whether the service is a covered service and is medically necessary and upon the member’s eligibility on the date(s) of service.
- Submitting cost and pricing information on a prior authorization request does not guarantee payment at the submitted rate. See section 2.3 for provider reimbursement guidelines.
3.5.1 Authorization Requests: Requirements and Timeframes
Prior Authorization Requirements: A request for authorization for services or items that require Plan authorization in advance of the service being rendered or the item being furnished.
Post Service Authorization Requirements: A coverage request for emergent or urgent admissions, non elective observation stays, admissions that follow observation stays and prenatal services are subject to clinical review and require Plan authorization within the specified timeframe following the date of service. See Request Timeframe requirements in the grid below.
Note: The Plan authorizes ancillary services and therapies (e.g., diagnostic tests, laboratory services, radiology services, occupational therapy, physical therapy, and speech therapy) during an inpatient admission if the admission is authorized.
Non-covered services (e.g., infertility services for MassHealth or Commonwealth Care members) provided in conjunction with an inpatient admission are not automatically authorized if the admission is authorized. If you have any doubt (1) that an inpatient admission has been authorized - contact our Acute Care Coordination Department; or (2) that a service is authorized in conjunction with an inpatient admission - contact our Prior Authorization Department.
Failure to follow the authorization requirements in this section will result in denial of claims payment. The provider will be liable for this service – the member may not be billed.
| Type of Service | Services Requiring an Authorization | Request Instructions | Request Timeframe Requirement | Party responsible for obtaining prior authorization |
|---|---|---|---|---|
| Select medical/surgical services and items | Services and items listed on the Prior Authorization Matrix located under the provider tab at bmchp.org Examples include but are not limited to home health care, outpatient rehabilitation therapies, elective inpatient and observation stays, and select ambulatory surgeries. |
Fax a completed Medical Prior Authorization Request Form to the Plan’s Prior Authorization department.
|
Requests must be submitted at least 5 calendar days before the requested date of service. | PCP or servicing provider |
| Changes or additions to services previously authorized by the Plan | Fax a completed Medical Prior Authorization Request Form to the Plan’s Prior Authorization department.
|
Requests must be submitted within five business days of the date of service. | Servicing provider | |
| Emergent or urgent admissions | Emergent or urgent inpatient admissions (including acute, SNF and rehab) for initial and ongoing care | Fax a completed authorization request to the Plan’s Acute Care Coordination department.
|
Requests must be submitted within 1 business day following the admission date. Note: An inpatient admission following observation status in the same episode of care requires a separate notification. |
Servicing facility or treating physician |
| Non-elective observation services | We cover medically necessary observation services up to a maximum of 48 hours. Medical necessity, not the number of hours the member is in observation, determines if a member’s care is appropriate for observation status. Any inpatient services received beyond the initial 48 hours must be reviewed and authorized by the plan against acute inpatient care criteria. |
Fax a completed authorization request to the Plan’s Acute Care Coordination department.
|
Requests must be submitted within one business day following initiation of observation services. | Servicing facility |
| Non-emergent transportation services | Non-emergent transportation covered under the member’s benefit plan Examples include but are not limited to non-emergency ground ambulance, chair car |
Fax a completed Medical Prior Authorization Request Form to the Plan’s Prior Authorization department.
|
Requests must be submitted within 3 business days following the date of service. | Servicing provider |
| Durable Medical Equipment, Prosthetics, Orthotics and Medical Supplies (DMEPOS) managed by Northwood, Inc. | All DMEPOS services dispensed and billed by the provider types listed to the right. Examples include, but are not limited to, crutches, wigs, prosthetics, oral enterals, and wheelchairs. |
For the following provider types:
Requests should be submitted to Northwood:
|
Requests for routine DMEPOS must be received by Northwood in advance of obtaining the item. Refer to the Northwood Provider Manual or contact Northwood Inc. at 866-802-6471 8:30 a.m. to 5 p.m. EST, Monday through Friday for specific timeframes and instructions. |
PCP, specialist or servicing supplier |
| Durable Medical Equipment, Prosthetics, Orthotics and Medical Supplies (DMEPOS) managed by BMCHP | Services and items listed on the Prior Authorization Matrix located under the provider tab at bmchp.org and dispensed and billed by the provider types listed to the right | For the following provider types:
|
Requests must be submitted at least five calendar days before the requested date of service. When dispensed due to a medically urgent condition requests must be submitted within two business days following the date of service. |
PCP or servicing provider |
| Advanced Elective Radiology (Routine or urgent requests) | Elective advanced radiology including:
Low-end radiology services (e.g., outpatient X-rays, mammography, fluoroscopy) do not require prior authorization when performed by a participating provider. |
Requests should be submitted to MedSolutions, Inc., the Plan’s contracted radiology management vendor, via the website, phone or fax.
|
|
PCP or servicing provider |
| Select Medications | Select medications listed on the Pharmacy page at bmchp.org. Prior authorization requirements apply to medications dispensed through retail and specialty pharmacies and the provider setting. | Fax a completed medication-specific form or submit an on-line request using the forms available on the Pharmacy page at bmchp.org. | Requests must be submitted two calendar days before the requested therapy start date. | PCP or servicing provider |
| Non-Covered Services | Requests for coverage of otherwise non-covered services For a list of services we do not cover, see section 13, Member Benefit Information. |
Fax a completed Medical Prior Authorization Request Form to the Plan’s Prior Authorization department:
|
Requests must be submitted at least five calendar days before the requested date of service. | PCP or servicing provider |
3.5.2 Member Access to Care without Prior Authorization
Emergency and Urgent Services
We cover emergency care for all members (for MassHealth members, emergency care is only covered in the United States and its territories). Determination of medical necessity for emergency services is based on the circumstances of the individual case and not on lists of diagnoses or symptoms. See section 8.9 for a description of a hospital’s responsibilities related to emergency care, Plan notification and PCP communication guidelines.
An emergency is defined as a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that, in the absence of prompt medical attention, could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in placing the health of a member or another person or, in the case of a pregnant woman, the health of the woman or her unborn child, in serious jeopardy, serious impairments to bodily function, or serious dysfunction of any body organ or part; or, with respect to a pregnant woman, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. Section 1395dd(e)(1)(B).
Urgent care is medically necessary care that is required to prevent serious deterioration of a member’s health when they have an unforeseen illness or injury. It does not include emergency or routine care. See section 3.5.3 for further information about urgent care.
For members identified as having high emergency room utilization, we assign a clinical care manager to assess whether the member's medical needs are being met, and whether the member understands and has access to recommended follow-up care identified by the emergency room physician. The clinical care manager also educates the member about the importance of the PCP relationship and its effectiveness on the member's overall care and well-being.
3.5.3 Out-of-Area Emergent (including post-stabilization) and Urgent Care
We recognize that members may have medical emergencies or require urgent care when they travel outside our service area.
| Type of Service | Out of Area Coverage Criteria |
|---|---|
| Emergent services, including post stabilization services | We cover emergency services (including medications or procedures deemed necessary during the course of the emergency treatment) provided to members who are out-of-area when members cannot safely wait to obtain services from an in-network provider. MassHealth members only - Coverage is provided only if the emergent care is provided in the United States and its territories. |
| Urgent care services | We cover urgent care services that are provided out-of-area when:
|
- We do not cover out-of-area non-emergent or non-urgent services, medications or procedures.
- We do not cover any services provided to MassHealth members outside the United States or its territories.
3.5.4 Other Special Circumstances Not Requiring Prior Authorization
Plan members can receive the following services without prior authorization when the treating provider is a Plan contracted provider:
- Prenatal and obstetrical care
- Gynecological care
- Routine vision exams - For MassHealth members only: once per 12 month period for Plan members under the age of 21 and once per 24 month period for Plan members over the age of 21; for Commonwealth Care and Commercial members: once every 24 months.
MassHealth Plan members can receive the following service(s) from any MassHealth provider qualified to furnish such services without prior authorization:
- Family planning services
- Early intervention services
A member may call our Member Services department at 888-566-0010 (MassHealth), 877-957-5300 (Commonwealth Care) or 1-877-492-6967 (Commercial plans) to verify that a provider is contracted with the Plan.
3.5.5 Prior Authorization Requirements for In-Network Specialty Care
At the time a specialist visit is requested, always verify that a facility is in-network by checking the product-specific online Provider Directory. Prior authorization is not required for in-network specialty care when:
- the specialist is affiliated with Boston Medical Center, or
- the Plan-contracted specialist is affiliated with the same hospital as the member’s primary care provider PCP, or
- care is administered by Plan-contracted specialists affiliated with any Plan-contracted hospital not listed below, or
- the service rendered is one of the first 12 outpatient visits to a Behavioral Health provider for MassHealth and Commonwealth Care Plan Type I members and the first eight outpatient visits to a Behavioral Health provider for Commonwealth Care Plan Type II and III and Commercial plans members.
Excluding visits related to services identified in section 3.5.4, prior authorization is required for visits to Plan-contracted specialists affiliated with the hospitals below unless the specialist and the member’s primary care provider (PCP) are affiliated with the same hospital:
- Beth Israel Deaconess Medical Center – all locations
- Carney Hospital
- Children’s Hospital – all locations
- Mount Auburn Hospital
- Saint Elizabeth’s Medical Center
- Tufts Medical Center
- Women and Infants Hospital of Rhode Island
When prior authorization is required, it will be granted for specialty care with specialists affiliated with the above hospitals when the specialty care is not available from a specialist affiliated with Boston Medical Center or from a Plan-contracted specialist affiliated with the same hospital as the member’s PCP.
Authorization requests may be submitted by the primary care physician or by the specialist utilizing the Medical Prior Authorization Request Form in section 15. Providers may also access BMC Connects, the BMC specialty appointment service, directly at 877-781-4763.
Failure to follow prior authorization requirements will result in administrative denial of claim payment.
3.5.6 Second Opinions
We do not mandate a second opinion for any service or procedure. However, all Plan members are entitled to a second opinion before commencing any recommended treatment plan or submitting to any surgical procedure. The PCP, upon request of the member, will initiate a consult with the second opinion physician. The member will make the final decision about the course of treatment. We provide coverage for a second opinion from a qualified healthcare professional within the Plan’s provider network, or arrange for the member to obtain a second opinion outside the provider network at no cost to the member if an in-network healthcare professional is not available. Prior authorization is required for a member to obtain an out-of-network second opinion.
3.5.7 New Technology, Experimental Diagnostics and Experimental Treatment
We evaluate new medical technologies and new uses for existing medical technology such as medical procedures, pharmaceuticals and devices, to determine whether they should constitute a covered service. We conduct these assessments to help us determine whether the technology improves health outcomes. The Plan does not cover experimental or investigational services except when required by law.
MassHealth defines experimental treatment as a service for which there is insufficient authoritative evidence that the service is reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions in the member that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a disability, or result in illness or infirmity.
For our Commonwealth Care and Commercial plans, experimental or investigational treatment is defined as a treatment, service, procedure, supply, device, biological product or drug (collectively “treatment”) for use in diagnosing or treating a medical condition if any of the following is true:
- In the case of a drug, device, or biological product, it cannot be marketed lawfully without the approval of the U.S. Food and Drug Administration (“FDA”) and final approval has not been given by the FDA.
- The treatment is described as experimental (or investigational, unproven, or under study) in the written informed consent document provided, or to be provided, to the member by the health professional or facility providing the treatment.
- The authoritative evidence does not permit conclusions concerning the effect of the treatment on health outcomes.
- There is insufficient authoritative evidence that the treatment improves the net health outcome. (Improved net health outcome means that the treatment’s beneficial effects on health outcomes outweigh any harmful effects of the treatment on health outcomes.)
- There is insufficient authoritative evidence that the treatment is as beneficial as any established alternative. This means that the treatment does not improve net outcome as much as or more than established alternatives.
- There is insufficient authoritative evidence that the treatment’s improvement in health outcomes is attainable outside the investigational setting.
“Authoritative evidence,” as used in this definition, means only the following:
- With reference to reports and articles of well-designed and well-conducted studies published in authoritative English-language medical and scientific publications: the publications must be subject to peer review by qualified medical or scientific experts prior to publication. In evaluating this evidence, we consider both the quality of the published studies and the consistency of results.
- With reference to opinions and evaluations by national medical associations, other reputable technology assessment bodies, and healthcare professionals with recognized clinical expertise in treating the medical condition or providing the treatment: In evaluating this evidence, we consider the scientific quality of the evidence upon which the opinions and evaluations are based.
The fact that a treatment is offered as a last resort does not mean that it is not an experimental or investigational treatment.
Our Medical Policy, Criteria, and Technology Assessment Committee (MPCTAC) regularly reviews information from clinically appropriate sources including peer-reviewed medical literature, professional societies, and regulatory agencies, and obtains expert opinions from specialist providers to determine whether a new or emerging technology is still investigational or whether it constitutes an accepted standard of practice. The MPCTAC uses the following five criteria to evaluate the literature and reach a coverage decision:
- The service or treatment must have final approval from the appropriate governmental regulatory bodies (e.g., the U.S. Food and Drug Administration), or any other federal governmental body with authority to regulate the technology. This applies to drugs, biological products, devices and other products that must have final approval to market the technology.
- The scientific evidence utilizing peer-reviewed literature and evaluations by national medical associations must permit conclusions concerning the effect of the service or treatment on health outcomes.
- The service or treatment must improve the net health outcome and should outweigh any harmful effect.
- The service or treatment must be as beneficial as any established alternative.
- The outcomes must be attainable outside the investigational settings.
3.6 Plan’s Utilization Management Timeframe
The utilization management policies and procedures are written in accordance with applicable regulatory requirements and accreditation standards. The Plan’s Timeliness of Utilization Review Decisions and Notification Policy includes decision and notification timeframes that:
- are established for standard, expedited, and retrospective requests for initial authorizations, extensions, denials and limited authorizations of service requests;
- apply to all utilization management requests received and processed by the Plan or its designee;
- provide the necessary guidance for consistent processing and triaging of requests within departments; and
- are intended to provide notice as expeditiously as the member’s health condition requires.
4.1 Plan’s Utilization Management Timeframe Requirements
The utilization management policies and procedures are written in accordance with applicable regulatory requirements and accreditation standards. The Plan’s Timeliness of Utilization Review Decisions and Notification Policy includes decision and notification timeframes that:
- are established for standard, expedited, and retrospective requests for initial authorizations, extensions, denials and limited authorizations of service requests;
- apply to all utilization management requests received and processed by the Plan or its designee;
- provide the necessary guidance for consistent processing and triaging of requests within departments; and
- are intended to provide notice as expeditiously as the member’s health condition requires.
4.1.2 Plan’s Requirements for Timeliness of Utilization Review Decisions and Notifications
We make and communicate utilization management prior authorization decisions to providers, the facility and members (if applicable) within the utilization timeframes listed below.
| PRODUCT | DECISION TIMEFRAMES | MEMBER AND PROVIDER NOTIFICATION TIMEFRAMES |
|---|---|---|
| Standard non-urgent pre-service request Definition: Any pre-service request that we review in advance of the member obtaining medical services. |
||
| MassHealth Standard non-urgent pre-service request (routine request) |
Medical service request decision: within 14 calendar days from receipt of request (ROR)* Pharmacy request decisions: within 1 business day of ROR Extension: Within 14 calendar days of initial request, Plan may extend review period an additional 14 calendar days with request letter to member and provider. Decision will be made at end of 14-day extension. * Receipt of Request (ROR) will be considered the date a fax is received or the received date stamp on a letter of medical necessity. For concurrent inpatient the “request date” will be considered the date that the requested services failed to meet the criteria. |
Approvals:
|
| Commonwealth Care/ Commercial Plans: Standard non-urgent pre-service request (routine request) |
Within two business days of receipt of all needed clinical info but no later than 15 calendar days of ROR No extensions permitted |
Approvals:
|
| Expedited or urgent pre-service request Definition: Any request for medical care or treatment with respect to which the application of the time periods for making non-urgent care determination could either seriously jeopardize the life or health of the member, based on a prudent layperson’s judgment or in the opinion of a practitioner with knowledge of the member’s medical condition, would subject the member to severe pain or injury that cannot be adequately managed without the care or treatment that is the subject of the request. |
||
| MassHealth Expedited or urgent pre-service request |
As expeditiously as the member’s health requires but no later than 72 hours of the ROR Pharmacy decisions must be rendered within one business day from ROR Extension: Decision will be made at end of 14-day extension |
Approvals:
|
| Commonwealth Care/ Commercial plans: Expedited or urgent pre-service request |
As expeditiously as the member’s health requires but no later than 72 hours of the ROR No extensions permitted |
Approvals:
|
| Continued stay/urgent concurrent Definition: Review for an extension of a previously-approved ongoing course of treatment over a period of time or number of treatments meeting the expedited definition. |
||
| MassHealth Continued stay/urgent concurrent |
Within 24 hours of ROR | Approvals:
|
| Commonwealth Care/ Commercial Plans Urgent concurrent review |
As expeditiously as the member’s health requires and no later than 24 hours of ROR | Approvals:
|
| Concurrent Non Urgent Definition: Review for an extension of a previously approved ongoing course of treatment over a period of time or number of treatments. |
||
| The concurrent non urgent timeframes are the same as the Standard non-urgent pre-service request timeframes outlined above. | ||
| Post-Service / Retrospective Review Definition: Any review for care or services that have already been received, (e.g. retrospective review). A request for coverage for care that was provided by an OON practitioner and for which the required pre-service authorization was not obtained. |
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| All plans post-service retrospective review |
No later than 30 days of ROR | Approvals:
|
4.1.3 Process for Post Service/Retrospective Requests
Post-service (retrospective) authorization requests will only be accepted and processed when a provider has demonstrated an inability to obtain an authorization within the required authorization timeframes above due to extenuating circumstances. Any request for the Plan to review a denial of a post-service request for failure to obtain an authorization within the required timeframe, will be processed as a provider administrative appeal.
A provider administrative appeal will be conducted when a facility or provider was required to obtain an authorization for the requested service but the authorization was not obtained due to extenuating circumstances. Examples of extenuating circumstances include:
- When the Plan has added the member retroactively, either during the course of continuing treatment or after the service was rendered. In this case, the provider must submit a request for retrospective authorization within 30 days of the member’s eligibility effective date with the Plan;
- When the provider was not able to verify the member’s eligibility because of circumstances that were beyond the provider’s control (e.g., member was unconscious); or
- When the provider can submit documented evidence that he/she received incorrect insurance information from the member.
Please see instructions for filing a provider administrative appeal in section 10. When filing a provider administrative appeal the provider should supply a written explanation of the extenuating circumstance that prevented him/her from obtaining an authorization or extending an existing authorization.
The Plan will review each qualifying provider administrative appeal to determine whether the request warrants a retrospective review by the Plan using the criteria in place on the date of service. We will notify you in writing whether or not the submitted request meets the qualifications for a retrospective review and, if it does, the outcome of the review.
Please remember that:
- We will not grant a retrospective review if you failed to follow the established authorization timeframe requirements and extenuating circumstances did not exist.
- We will not grant a retrospective review as a provider administrative appeal if the request is related to an adverse determination/action (a denial or limited authorization of requested services, or reduction, suspension, or termination of a previous authorization due to medical necessity or benefit reasons). These requests should be directed to the Member Appeals department. Member appeals rights and instructions for filing an appeal are outlined in the member’s benefit documents and in the denial decision letter.
In the event of an adverse determination based on lack of medical necessity, a provider can request a reconsideration of the determination. See section 10 for instructions on how to request a reconsideration of an adverse determination/action.
5.1 Services that Require Plan Notification
The Plan must be informed, as described below, about certain services a member has already received or of specific changes in a member’s health status. This notification assists Care Managers in identifying those members who might benefit from care management involvement. Notification also allows the Plan to monitor utilization and to initiate actions to improve service.
| Type of Service | Notification Instructions | Notification Timeframe | Party responsible for Notification |
|---|---|---|---|
| Newborn Birth | For MassHealth, Commonwealth Care and Commercial plans products: Fax all newborn statistical information to our Enrollment department (not the Prior Authorization Department) within 24 hours of the delivery. We will only accept notification by fax, and the notification must be directed to our Enrollment department (not the Prior Authorization department). The Enrollment department’s fax number is 617-897-0838. |
Within one business day of a newborn delivery | Servicing facility |
| Delivery | Notifications post delivery may be sent via fax to the Plan’s Acute Care Coordination department.
|
In advance for planned C-sections. Within one business day of the delivery for all other deliveries. |
Servicing facility |
| Newborn Hospitalization Following Mother’s Discharge | For MassHealth and Commonwealth Care. For Commercial only when newborn has been added to the Plan:
|
Prior to the mother’s discharge if newborn remains inpatient | Servicing facility |
| Confirmed Pregnancy | Notifications may be sent via telephone or fax to the Plan’s Prior Authorization department
|
Within three business days of each confirmed pregnancy of a Plan member | Obstetrics provider |
5.1.2 Maternity Program Notification Requirements
Our maternity program focuses on identifying high-risk pregnancies early, and implementing appropriate interventions. You must notify our Prior Authorization department within three business days of each confirmed pregnancy of a Plan member. For each notification of a pregnancy, our Prior Authorization department makes a referral to the Care Management department. A member of the Plan’s Care Management staff conducts a prenatal assessment to determine if the member is at high risk and would benefit from care management services. The Care Management staff records the member’s estimated date of confinement (EDC), assesses for risk, tracks the prenatal care, makes referrals to educational services, and conducts outreach, as necessary.
5.1.2.1 Prenatal Home Care Visits
Prenatal home care services are available for Plan members, when medically necessary. Our Care Management or Prior Authorization staffs will assist the PCP or obstetrician in arranging these services.
5.1.2.2 Third Trimester Pediatrician Visits
We support the American Academy of Pediatrics “Prenatal Visit to the Pediatrician” initiative and will reimburse pediatric clinicians who provide this service to prenatal members. This service does not require Plan authorization.
5.1.2.3 Out-of-Network Exceptions for Pregnant Members
A Plan member who is pregnant must receive care from a Plan-contracted provider in the appropriate Plan network. For continuity of care purposes, we will consider exceptions to this policy only if either of the following apply:
- The woman was in her second or third trimester of pregnancy when she became a Plan member and she has an established relationship with a non-participating obstetrical provider.
OR - Her Plan-participating provider becomes non-participating while the Plan member is in her second or third trimester
We may consider other network exceptions if the member:
- Speaks a language not spoken by any network obstetrician; or
- Lives more than 30 miles away from any network obstetrician
We must authorize all out-of-plan maternity care, including delivery at the facility where the non-network obstetrician is affiliated.
5.1.2.4 Notification of Delivery
Hospitals must notify the Plan’s Prior Authorization department of planned C-sections in advance. Hospitals must notify the Plan of all other deliveries within one business day of the delivery.
5.1.2.5 Postpartum Home Care Visits
Plan prior authorization is not required for an initial, postpartum follow-up home care visit if performed by a Plan-contracted provider. (Exception: see section 5.1.2.7 below.) This visit includes services for both the mother and newborn(s); therefore, a separate claim form or claim line cannot be billed for the newborn.
If during the postpartum visit it is determined that the newborn or mother requires urgent or emergent services, the home health provider should refer the member to the PCP and/or to an emergency room, whichever is clinically appropriate. If at the time of the postpartum visit it is determined that the newborn or mother requires immediate services, the home health provider is required to refer the member to the emergency department after first rendering appropriate care in anticipation of transport. The home health provider is required to refer the member to the PCP If it is determined that the newborn or mother requires physician services during the initial postpartum visit. Decision-making (triage) for referral and provision of care under these circumstances is included in the reimbursement for the postpartum follow-up visit.
Additional home care services rendered beyond the postpartum follow-up home visit require Plan prior authorization. This applies to both the mother and the newborn(s). If a home health provider determines that additional visits are required during the postpartum follow-up visit (for either a newborn or the mother), the home health provider must contact the PCP and the Plan to obtain the appropriate authorization. Failure to obtain an authorization for subsequent visits to the mother or the newborn will result in claim denials.
5.1.2.6 Notification of Newborn Birth - MassHealth and Commonwealth Care only
You must notify the Plan whenever a member gives birth so that we can reimburse the facility for the hospital and associated ancillary services rendered. Fax all newborn statistical information to our Enrollment department within 24 hours of the delivery. We will only accept notification by fax, and the notification must be directed to our Enrollment department (not the Prior Authorization department). The Enrollment department’s fax number is 617-897-0838. This fax should include the following information:
- Newborn mother’s first and last name
- Newborn mother’s member ID number
- Newborn mother’s address and phone number
- Newborn’s first and last name
- Birth weight (in grams)
- Gender
- Gestational age
- Date of delivery
Once notified, our Enrollment department creates a temporary, Plan-specific member ID number (called a T-number) for the newborn and faxes this information back to the hospital for billing purposes within two business days. The T-number is the only number required for billing purposes.
For MassHealth and Commonwealth Care newborns only, the hospital also must complete a MassHealth Notification of Birth (NOB-1) form and submit it to MassHealth no later than 30 calendar days after the delivery. Hospitals should contact MassHealth if there are questions related to the NOB-1 form. MassHealth generates a member ID number for the newborn. Failure to submit the NOB-1 form to MassHealth may result in claim retractions for any payments made for the child’s admission if no MassHealth ID number is issued.
See section 8.2 for additional information on how to report a delivery, verify eligibility of a newborn, and generate a T number and MassHealth ID number for the newborn. The T number and MassHealth ID number are necessary for member enrollment and billing of newborn services. Please review Billing Newborn Care in section 2.15 for instructions on how to bill for the inpatient stay and all services for a newborn child.
We also require newborn prior authorization if one of the following situations occurs:
- The newborn remains in the hospital after the mother is discharged.
- The newborn is transferred to the level-two nursery or to the NICU.
Failure to obtain authorization could result in denial of the newborn claim.
5.1.2.7 Notification of Newborn Hospitalization Following Mother’s Discharge
For MassHealth and Commonwealth Care as below. For Commercial, when the newborn has been added to the Plan.
The hospital must notify our Prior Authorization department when a newborn remains in the hospital after the mother is discharged. Notification should occur prior to or at the time of the mother’s discharge. When requesting authorization for an extended hospitalization of a newborn after the mother’s discharge, include the following information:
- Reason for continued hospitalization
- Diagnosis(es)
- Name of attending neonatologist
- Gestational age
We require prior authorization for any home care visits needed by the newborn upon its discharge after an extended hospitalization when the newborn is discharged after the mother. In this case, you must get prior authorization for the initial visit as well as any subsequent visits.
