Utilization Review

Utilization review is a process by the health plans to monitor and evaluate the necessity and appropriateness of health care services. Types of utilization review include, but are not limited to:

• Ambulatory review
• Case management
• Certification
• Concurrent review
• Prospective review (prior to an admission or treatment)
• Retrospective review (after services are provided)
• Second opinion

Utilization review does not include:

• Elective requests for clarification of coverage.
• Claims limited to an evaluation of reimbursement levels.
• Veracity of documentation.
• Coding accuracy.
• Adjudication for payment.

A member or the member’s provider may request coverage of medically necessary durable medical equipment (i.e. wheelchairs, walkers, insulin pumps, etc.) as part of the health plan’s utilization review process.

Initial Determinations
The health plan must make a decision within two working days of obtaining all necessary information regarding a proposed admission, procedure or service requiring a review determination.

Required Notification Timeframes: For certifications of admissions, procedures or services: the health plan must notify the provider by telephone within 24 hours of making the decision, and provide written or electronic confirmation to the member and the provider within two working days of making the decision.

For adverse determinations: the health plan must notify the provider by telephone within 24 hours of making the decision and shall provide written or electronic confirmation to the member and the provider within one working day of making the decision.

Concurrent Review Determinations
The health plan must make the determination within one working day of making the decision, and provide written or electronic confirmation to the member and the provider within one working day after the telephone notification. The written notification shall include the number of extended days or next review date, the new total number of days or services approved, and the date of admission or initiation of services.

For adverse determinations: the health plan must notify, by telephone, the provider rendering the service within 24 hours of making the adverse determination, and provide written or electronic notification to the member and the provider within one working day of the telephone notification.

Retrospective Review Determinations
The health plan must make the decision within 30 working days of receiving all necessary information. The health plan must provide notice in writing to the member within 10 working days of making the decision.

Reconsiderations of Initial Determination or Concurrent Review Determinations
The provider rendering the service to the member may request on behalf of the member a reconsideration of an adverse determination by the reviewer making the adverse determination. Such reconsideration shall occur within one working day of receipt of the request and shall be conducted between the provider and the reviewer who made the adverse determination or a clinical peer designated by the reviewer if the reviewer who made the adverse determination is not available within one working day. If the reconsideration process does not resolve the difference of opinion, the member or the provider may request that the adverse determination be heard through the following outlined grievance procedure. Reconsideration is not a prerequisite to filing a grievance or an expedited grievance of an adverse determination.