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Provider and Facility Reference Manual

Section 5 - Utilization Management Overview

Program Objectives

Blue Cross Blue Shield's Utilization Management (UM) Program is a dynamic process whose goal is to facilitate member health management throughout the continuum of care. The Program is tailored to meet the individual needs of our members for medical and behavioral health services. For additional information on our behavioral health program, see section 18.

Our Utilization Management staff uses an integrated process to help ensure access to care for both members and providers. The Utilization Management team, through the use of new technology, focuses on those providers, members or diseases to identify and facilitate the implementation of best practices in the delivery of quality, cost-effective care.

We:

  • Identify barriers to care
  • Monitor health care for under and over utilization
  • Track cost effectiveness through trend analysis

The interventions we develop take into account local practice and changing technology. We work to enhance the health of our members by facilitating the improvement of clinical outcomes through mutually beneficial partnerships with providers.
We support our providers and members with valuable, trusted information to facilitate and jointly plan for the delivery of the right clinical care, in the most appropriate setting, at the right time, with the right provider and at a reasonable cost, without compromising quality.
The Utilization Management Program has nine primary objectives:

  1. Quality Care: Provide quality care for our members throughout the health care continuum.
  2. Utilization Trends: Analyze trends and patterns of utilization and, based on our analysis, recommend improvements to access and quality of care. Through trending we also identify those services that may require additional scrutiny.
  3. Medical Appropriateness: Develop and apply standards and guidelines and ensure that our decisions are fair and consistent based on those standards.
  4. Service Appropriateness: Monitor the appropriateness and outcomes of services that health care institutions, contracted physicians, and contracting non-physician providers supply to our members. Any questionable cases are forwarded to the Health Care Quality Improvement or Special Investigational Unit for review.
  5. Appeals Process: Establish and maintain a mechanism for member appeal of adverse determinations, as defined by regulatory and legislative requirements. We provide an appeal process to our providers as defined in their contract, and legislative changes.
  6. Corrective Actions: In order to maintain high standards of quality and cost efficiency throughout the organization, we perform educational and other corrective actions to remedy identified deficiencies.
  7. Medical Care Delivery Initiative: Continually evaluate the Health Delivery System to manage the changing philosophy of Utilization Management. We redesign our approach to managing care and structuring of our delivery system by:
    • Referring all cases that could value from a case/disease intervention for case and disease management.
    • Maximizing the advantage of information technology available to us.
  8. Vendor Oversight: Blue Cross Blue Shield delegates specific Utilization Management functions to a number of vendors. Blue Cross Blue Shield seeks to align with vendors who are an expert in their field and have attained national certifications.

Our vendors maintain their own UM Program, which is approved by Blue Cross Blue Shield's Vendor Joint Oversight Team and reports to the Quality Management Committee. Vendor physicians are involved in our clinical committees upon request.

Utilization Management conducts yearly audits that include a review of policies, procedures and operational functions of the Utilization Management Department.
File audits are conducted on a quarterly basis.

  • Radiology Utilization - Blue Cross Blue Shield delegates specific radiology management to National Imaging Associates (NIA). NIA has NCQA certification.
  • eviCore healthcare -  Utilization Management specific for Post Acute Care (PAC) management of defined group of Medicare Advantage members who have multiple comorbidities. eviCore healthcare has NCQA certification.
  • Amerigroup - Blue Cross Blue Shield delegates all Utilization Management to Amerigroup ONLY for Managed Medicaid and Child Health Plus (CHP) lines of business.

    9. Utilization Management Satisfaction Team: The Utilization Management Department will evaluate the need for additional programs (or enhancement of current          programs) to increase customer satisfaction at all levels, i.e., members,  providers and employer groups.

Utilization Management


Purpose

The Utilization Management Department follows a proactive care management model ensuring all our members:

  • Timely access to quality care
  • Enhanced opportunities for referrals to Case and Disease Management

It is the responsibility of Utilization Management staff to ensure quality care in the most appropriate setting for all members. Utilization Management staff provides all our members with comprehensive medical management by coordinating the processes of preauthorization and level of care review.

Treatment Plans

Utilization Management nurses are trained to discuss short- and long-term treatment plans, including social and environmental impacts on the healing process. Our nurses follow the Utilization Management philosophy of identifying potential chronic problems early and establishing a link with a case manager. When a specialized service or procedure is requested, the nurse interacts with the physician to select and implement preventive or supportive care using either individual case or disease management programs.

Discharge Planning

From the time of admission, we collaborate with discharge planning to ensure adequate time to initiate a safe and comprehensive plan of care.

Member and Provider Access

Nurses are available to review telephone requests and questions from Blue Cross Blue Shield members and practitioners/providers with regard to the Utilization Management process including treatment plan options, expedited appeals for adverse determinations, and access-to-care interventions.

During business hours
From 8:15 a.m. to 5 p.m., EST, Monday through Friday, a member or physician may call the Utilization Management Department at 1-800-677-3086 to speak with a nurse.

From 8:15 a.m. to 5 p.m., EST, Monday through Friday, a member or physician may call the Behavioral Health Utilization Management Department at 1-877-837-0814 to speak with a nurse.

  • Staff will identify themselves by name, title and organization name when initiating or returning calls regarding Utilization Management issues.
  • Staff has ability to place outbound communications regarding inquiries during normal business hours.

After business hours
Nurses and physicians are also available at 1-800-677-3086 for expedited appeals and urgent access to medical services.

  • You may: Leave information for a return call the next business day or stay on the line and be forwarded to our exchange service. They will then take member and practitioners/provider information and contact the nurse on-call for urgent admissions and/or expedited appeals.
  • For non-urgent services, requests received after business hours (5 p.m.) will be processed the next business day.

Note: Urgent/emergency admissions do not require preauthorization.

Criteria/Medical Appropriateness Review

Blue Cross Blue Shield conducts medical appropriateness reviews to determine the appropriateness of a service. A pre-admission review is performed prior to admission on the elective surgical procedure being performed (NOT level of care), concurrently during an episode of care, and retrospectively to determine that procedures are medically necessary and appropriate for a specific condition. If health services are approved, Blue Cross Blue Shield will not modify standards or criteria during the same course of treatment.

Medical Appropriateness Review Guidelines

The guidelines promote cost-effective allocation of medical resources by identifying cases that:

  • May not reflect accepted medical process.
  • May benefit from alternative treatment modalities or settings.

We follow both licensed (InterQual® Criteria) and Corporate Medical Protocols for medical appropriateness review.
Refer to the Corporate Medical Protocols in Section 8 for additional information.

Application of Guidelines

Application of the guidelines allows for quick approval for a defined number of members. It is the responsibility of care managers to collect relevant clinical information. If guideline requirements are not met, the physician reviewer must be consulted for final determination.

We consider at least the following factors when applying criteria to a given individual:

  • Age
  • Comorbidities
  • Complications including risk factors and functional status
  • Progress of treatment
  • Psychosocial factors
  • Home environment/availability and adequacy of supports, when applicable

We also consider characteristics of the local delivery system that are available for the particular member, such as:

  • Availability of skilled nursing facilities, sub-acute care facilities, outpatient services, or home care in the Blue Cross Blue Shield service area to support the patient after discharge
  • Ability of local hospitals to provide all recommended services within the estimated length of stay
  • Coverage benefits

Discussing an Adverse Determination

Practitioners who would like to discuss a denial decision based on medical necessity with our physician reviewers may do so by calling 1-800-677-3086

You may also discuss the adverse determination with our physician reviewers at the time you are notified by phone of our determination. You may request the criteria used by Utilization Management to render our decisions by calling the number above or sending a written request to:

Highmark Blue Cross Blue Shield of Western New York
Attn: Utilization Management
PO Box 80
Buffalo, NY 14240-0080

Coverage Decisions Based on Appropriateness of Care

Blue Cross Blue Shield bases its medical necessity decisions on the appropriateness of care and services. Coverage decisions are based on the benefits and provisions contained in members' contracts. Blue Cross Blue Shield does not reward or offer incentives to practitioners, providers or staff members for issuing denials or for encouraging inappropriate under-utilization of care.

Preauthorization Review

A preauthorization review is performed for:

  • Select outpatient procedures
  • Select durable medical equipment
  • Certain medical/surgical benefits as notified by our Protocols or STAT Bulletins
  • Elective hospital admissions for all facilities
  • Admissions to rehabilitation and skilled nursing facilities
  • Behavioral health inpatient & outpatient
  • Home health care, if specified by contract
  • Potential cosmetic procedures
  • Potential experimental procedures
  • Out-of-plan requests
  • Select new technology

Blue Cross Blue Shield applies all medical appropriateness and appeal rights as per the New York State Department of Health (NYSDOH), New York State Department of Financial Services (NYSDFS), Federal Department of Labor (DOL), National Committee for Quality Assurance (NCQA) and Center for Medicare and Medicaid Services (CMS).

Urgent/emergency admissions do not require preauthorization. Once notified of admission, medical information is applied against InterQual® Criteria for level of care review.

Medical/Surgical Benefits

Blue Cross Blue Shield facilitates predetermination of benefit eligibility under the following conditions:

  • When we receive a predetermination request
  • When services or procedures may be a contract exclusion, such as cosmetic vs. reconstructive or dental vs. medical procedures

Medical Necessity Definition

Medical necessity means health care and services that are necessary to prevent, diagnose, manage or treat conditions in the person that cause acute suffering, endanger life, result in illness or infirmity, interfere with such person's capacity for normal activity, or threaten some significant handicap.

We will reimburse for medically appropriate care that is not more costly than alternative services or supplies at least as likely to produce equivalent results for the person's condition, disease, illness or injury.

Level of Care Review

Level of care review is conducted throughout a member's hospitalization through telephone, fax or on-site review using InterQual® criteria that includes the McKesson InterQual® Guidelines for Surgery and Procedures in the Inpatient setting list. Documentation of the member's clinical condition is essential to ensure the appropriate setting and level of care required.
If an initial review for level of care assignment is not conducted by the health plan and/or the information provided is inaccurate, lacking, missing or unavailable, Blue Cross Blue Shield reserves the right to perform a retrospective review to determine the level of care for reimbursement.

Nurses' Role
Working in collaboration with the hospital's Utilization Review Department, Blue Cross Blue Shield's nurses obtain and review relevant medical information on-site or by phone/fax. The purpose of the review is to:

  • Monitor service quality and access
  • Assist in discharge planning
  • Establish level-of-care determinations using InterQual® criteria
  • Act as a resource to both the hospital and the physician
  • Link members to case/disease management programs and community-based programs
  • Assist physicians in identifying alternatives to continued hospitalization
  • Help the facility, physician, or member exercise appeal rights when one of our physicians makes a level-of-care determination in accordance with the Adverse Medical Determination Policy

Observation Level of Care

Observation status, when used as an alternative to an acute hospital admission, is eligible for reimbursement for patients who meet InterQual® Observation criteria and require:

  1. Further frequent cardiac, neurologic, or other physiologic monitoring and assessment
  2. Evaluation or testing to determine a diagnosis
  3. Extended definitive emergency department care and/or non-elective treatment (i.e., IV hydration, IV antibiotics)

A designated bed and/or unit are not required. For example, a patient in observation status may be located in an emergency room bed, medical bed, surgical bed, etc.
Services and treatment rendered in an observation bed are separate and in addition to emergency room services. An individual's dated and timed medical record must be maintained, including physician orders, progress notes, nurses' notes and the rationale for acuity evaluation status.

Observation services generally do not exceed, but are not limited to, 24 hours.

The following do not qualify for Observation reimbursement:

  • Services that do not meet InterQual® criteria
  • Services for the convenience of the patient or physician
  • Services not covered under the patient's contract

Maternity Admissions

Preauthorization is not required for vaginal deliveries or cesarean section admissions within 96 hours of delivery. While preauthorization requirements have been removed to comply with the New York State mandate prohibiting preauthorization within 48 hours of delivery, Blue Cross Blue Shield fully expects that only appropriate and medically necessary services will be rendered. Blue Cross Blue Shield reserves the right to conduct post-payment reviews to assess the medical appropriateness of the aforementioned procedures rendered for benefit coverage.

Rehabilitation and Skilled Nursing Facilities

Admissions to both rehabilitation and skilled nursing facilities are covered if the following conditions are met:

  • Preauthorization is mandatory prior to arranging admission to a participating facility
  • The condition, illness, or injury meets medical necessity
  • The terms and conditions of the Blue Cross Blue Shield contract are in effect

Ambulatory Surgery

Ambulatory surgery procedures will not be considered for inpatient reimbursement unless there is evidence using InterQual® criteria which includes the McKesson InterQual® Guidelines for Surgery and Procedures in the Inpatient setting list. Please refer to the protocol section of this manual when billing ambulatory surgery services.
NOTE: Post payment audits may be performed to ensure appropriate care is provided to our members.

Urgent Care

Blue Cross Blue Shield defines urgent care as medical care or treatment for which failure to make an expeditious determination could seriously jeopardize the life or health of the patient or the ability of the patient to regain maximum function or, in the opinion of a physician with knowledge of the patient's medical condition, would subject the patient to severe pain that can't be adequately managed without the care or treatment requested.
Urgent Care requests that are received will follow the Federal guidelines in respect to timeframes. A response will be rendered within 72 hours if all necessary information is received at the time of the initial request.

In accordance with Federal guidelines, response to Urgent Care requests will be rendered within 72 hours, if all necessary information is received at the time of the initial request.
To efficiently assist our providers, urgent requests due to schedule changes or unforeseen circumstances, will be handled as routine requests and handled within three business days, if all medical information is received at the time of the request.

If medical records are not provided, requests will be handled within three business days of receipt of appropriate medical information.
Blue Cross Blue Shield's Away From Home Program covers a member for urgent care when away from home. Members needing out-of-area urgent care should contact their PCP for guidance to care. All provisions of the Urgent Care Out-of-Area policy will apply.

Emergency Care Definition

Emergency care is defined as the sudden onset of a medical or behavioral condition that manifests itself by symptoms of sufficient severity, including severe pain. In this situation, a prudent layperson with an average knowledge of medicine and health could reasonably expect the absence of immediate medical attention to result in one or more of the following:

  • Placing the health of the person afflicted with the condition in serious jeopardy, or in the case of a behavioral condition, placing the health of the person or others in serious jeopardy
  • Serious impairment to bodily functions
  • Serious dysfunction of any bodily organ or part
  • Serious disfigurement

Blue Cross Blue Shield does not preauthorize emergency services and we do not deny emergency care on a retrospective basis; however, we may identify specific diagnoses to pend for medical review to determine if the rationale for seeking care in an emergency room setting meets the intent of the New York State Prudent Layperson Law. After review by a physician, Blue Cross

Blue Shield will treat identified non-emergency care as an adverse determination and all provisions of Adverse Determination Policy will be applied.

Emergency services, including Comprehensive Psychiatric Emergency Program (CPEP) and Office of Mental Health/ Office of Alcoholism and Substance Abuse Services (OMH/OASAS) Crisis Intervention and OMH/OASAS-specific non-urgent ambulatory services are not subject to prior approval.

Time Frames for Preauthorization Review

The following timeframes must be met for preauthorization reviews:

  1. Non-Urgent Care
    1. (Pre-service claims) A decision is made within three business days of obtaining all necessary information
    2. Notification for approvals and denials are made to the member or the member's designee and the member's health care provider by telephone and in writing
       
  2. Urgent Care
    1. (Pre-service claims) A decision is made 72 hours after receipt of request.
    2. Notification for approvals and denials are made to the member or the member's designee and the member's health care provider by telephone and in writing.
       
  3. Concurrent Care
    1. A decision is made within 24 hours or one business day (whichever occurs first) after receipt of request.
    2. Notification for approvals and denials are made to the member or the member's designee, which may be satisfied by notice to the member's health care provider, by telephone and in writing.
  4. Post-Service
    1. A decision is made within 30 days after receipt of the necessary information.
    2. Notifications for denials are made to the member or the member's designee and the member's health care provider in writing.

For Medicare Advantage

Standard Organization Determinations
A decision is made as expeditiously as the member's health condition requires, but no later than 14 calendar days after receipt of request for medical services/items and 72 hours for Part B drugs.  A 14 calendar day extension may be issued for only medical services/items if the plan requires additional medical information to render a decision or the member, designee or provider requests an extension. There is no extension for Part B drug requests.

Expedited Organization Determinations
A decision is made as expeditiously as the member's health condition requires, but no later than 72 hours after receipt of request for medical services/items and 24 hours for Part B drugs.  A 14 calendar day extension may be issued if the plan requires additional medical information to render a decision.

There is no extension of Part B drug requests.

Appeal Rights for Preauthorization Review

Preauthorization review denials may be appealed:

  • In the event of adverse determination the Medical Director or physician designee (clinical peer reviewer) is available to discuss the reasons for the denial.
  • If the Medical Director fails to communicate with the requesting provider, the provider can request reconsideration.
  • Failure to comply with timeframes for initial determination is treated as an adverse determination, which the member may appeal. Notice must be sent on the date review timeframe expires.

Adverse Medical Determinations

Only physicians (clinical peer reviewer) may render adverse medical determinations. Adverse determinations may be appealed following the adverse medical determination.

Notice of Adverse Determination
Both the member and the provider are notified of any adverse determinations. The notice of adverse determination must:

  • Be made both verbally and in writing to the member and to the practitioner.
  • Include rationale underlying any finding that the service was not medically necessary in easily understandable language and the clinical review criteria used to make the decision.
  • Include the availability of the physician reviewer.
  • Instructions on how to request a copy of the clinical review criteria used to make the determination or the clinical determination of the physician reviewer.
  • A description of appeals rights (standard and expedited appeals) including the right to submit written comments, documents, or other information relevant to the appeal.
  • An explanation of the appeals process, including the right to member representation and timeframes for deciding appeals and eligibility for external appeals.
  • Include the phone number of the Plan contact for external appeal, if applicable to the member's contract.
  • Include the toll-free phone number of the DOH and/or the DOI, if applicable to the member's contract.
  • What additional information, if any, would be necessary to render a decision on appeal.

For Medicare Advantage Members
Medicare Advantage members are entitled to certain appeal rights pertaining to disputes about payment for, or failure to arrange (or continue to arrange) for, what the member believes are covered services (including non-Medicare covered benefits) under Medicare Advantage.

A member may appeal any adverse initial organizational determination.

A participating Medicare Advantage provider who is party to the appeal because they provided the service cannot file a Request for Reconsideration (Appeal). If health services are approved, Medicare Advantage will not modify standards or criteria during the same course of treatment. For further information on this process refer to Appendix 1.

Reconsideration Review
If attempts to discuss with the provider an initial adverse determination by the Plan's Medical Director are unsuccessful, the provider may request reconsideration. Except in cases of retrospective reviews, such reconsideration shall take place within one business day of the request. The provider is expected to share information via telephone and fax to provide the reviewer with complete information regarding the case. Once the necessary clinical information is received, reconsideration is conducted by the member's health care provider and clinical peer reviewer.

Blue Cross Blue Shield may reverse a preauthorized treatment, service or procedure on retrospective review when:

  • Relevant medical information presented upon retrospective review is materially different from the information that was presented during the preauthorization review; and
  • The information existed at the time of the preauthorization review but was withheld or not made available; and
  • The clinical reviewer was not aware of the existence of the information at the time of the preauthorization review; and
  • Had they been aware of the information, the treatment, service or procedure being requested would not have been authorized.

Utilization Management Appeal Process

The Utilization Management Appeal Procedure is designed to ensure a timely review of denied services or treatments to determine whether the services or treatments are:

(i) Medically necessary;
(ii) Experimental or investigational in nature;
(iii) Cosmetic in nature;
(iv) Or, in certain cases, out-of-network.

A member or the member's designee may appeal an out-of-network denial by submitting (a) a written statement from the member's attending physician, who must be a licensed, board certified or board eligible physician qualified to practice in the specialty area of practice appropriate to treat the member for the health service sought, that the requested out-of-network health service is materially different from the health service the health care plan approved to treat the member's health care needs; and (b) two documents from the available medical and scientific evidence that the out-of-network health service is likely to be more clinically beneficial to the member than the alternate recommended in-network health service and for which the adverse risk of the requested health service would likely not be substantially increased over the in-network health service.

Under the Utilization Management Appeal Procedure, the right to appeal an adverse determination on a medical necessity basis or an experimental/investigational basis will be made available to the member, or their designated representative, which could be their provider. An adverse determination based on contractual language should be forwarded to the Grievance Department.
To improve accuracy and consistency, the UM appeals team administers the Utilization Management appeals process described below and provides support to Member Services for all grievances that require input from Utilization Management.

The right to appeal an adverse determination is made available to all members or their designated representative, which could be their provider. Providers may appeal retrospective UM denials on their own behalf.

The appeal process is an appeal of an adverse determination, whether standard or expedited. The determination of an appeal on a clinical matter will be made by personnel qualified to review the appeal, including who did not make the initial determination and who are not a subordinate of the individual who made the initial determination.

To submit verbal and/or written appeal requests, contact us at:
1-800-677-3086 (toll-free)

Utilization Management Appeals Unit
PO Box 80
Buffalo, NY 14240-0080
Fax: 1-716-887-7913

Appeal Levels

There are two kinds of adverse determination appeals—standard and expedited. Appeals are offered at one level internally. The member must be notified of all appeal process rights.

Internal Appeal Process

The initial appeal process is an appeal of an adverse determination, whether standard or expedited. The determination of an appeal on a clinical matter will be made by personnel qualified to review the appeal, including licensed, certified or registered health care professionals who did not make the initial determination and who are not subordinates of the individual who made the initial determination. The health care professional shall either:

(i) have appropriate training and experience in the field of medicine involved in the appeal, or
(ii) consult with one or more health care professionals who have appropriate training and experience in such medical field.
If a panel of practitioners is utilized in reviewing an appeal, the panel must include at least one practitioner from the same or similar specialty as that which typically manages the medical condition, procedure or treatment.

Standard Appeal

Deadline for Requesting an Appeal
Requests for an appeal of an adverse determination may be made by telephone or in writing within 180 days after the member receives notification of the adverse determination. In the event that the member's claim involves Urgent Care, the expedited appeals process would be implemented. Otherwise the standard appeals process is to be used.
Procedure for conducting a standard appeal:

  1. Once an appeal is received, pertinent medical records will be requested from the provider (if not already submitted).
  2. Written acknowledgment of Blue Cross Blue Shield's receipt of the appeal request will be sent to the party requesting the appeal 15 days of filing the appeal.
  3. If information is necessary to conduct a standard appeal, the member and the member's health care provider are to be notified, in writing, within15 days of receipt of the appeal, to identify and request the necessary information.
  4. If only some of the requested information is provided, Blue Cross Blue Shield will make a second request for the missing information in writing, within five business days of receiving the incomplete information.

Time Frame Compliance

A decision will be rendered no later than 30 calendar days of receipt of appeal request for pre-service appeals and 60 calendar days of receipt of appeal request for post-service appeals. For Commercial, Indemnity, and Exchange plans, a decision will be rendered no later than 30 calendar days of receipt of appeal request (pre-service and post service appeals).  Written notice to enrollee, the enrollee's designee, and provider will be sent within two business days of the appeal decision.

Files

Blue Cross Blue Shield maintains files on all appeal requests and decisions.

Expedited Appeal

Eligibility for Expedited Appeal process is available to members appealing adverse determinations involving:

  • Continued or extended health care services
  • Procedures, treatments, or additional services for a member undergoing a course of continued treatment prescribed by a health care provider
  • Situations in which a health care provider believes an immediate appeal is warranted, except post service adverse determinations
  • Any situation that would increase risk to the member's health
  • Denial for home health care services following a discharge from a hospital admission
  • You are asking for more inpatient substance abuse treatment at least 24 hours before you are discharged; or
  • You are asking for mental health or substance abuse services that may be related to a court appearance

If Blue Cross Blue Shield requires information necessary to conduct an expedited appeal, Blue Cross Blue Shield shall immediately notify the member and the member's health care provider by telephone or facsimile to identify and request the necessary information followed by written notification.
The clinical peer reviewer will be available within one business day, or sooner.

Expedited appeals not resolved to the satisfaction of the appealing party may be re-appealed via the standard appeal process or through the external appeal process.

Time frame Compliance for Expedited Appeal

A decision will be rendered no later than two business days or 72 hours, whichever is less, after receipt of appeal request. Immediate notification of the decision will be given by telephone, followed by written notice, which will be sent within 24 hours of the appeal decision, but not to exceed two business days or 72 hours, whichever is less. Failure to comply with time frames for an internal appeal of a utilization review determination is deemed a reversal of the initial determination.

Full and Fair Review Process:

This is for all lines of business except Medicare Advantage and ASO that are grandfathered per HR3590H.R. Patient Protection and Affordable Care Act (PPACA).

The purpose is to provide the claimant with all the new or additional evidence that the plan considers, relies upon, or generates in connection with an appeal that was not available when the initial adverse determination was made.

The claimant will be provided any and all additional information submitted during their appeal process which resulted in a final adverse determination (FAD).

Final Adverse Determination of an Internal Appeal Process

Each final adverse determination of an Appeal is sent to the member or their designated representative and provider, and must include the following information:

  1. A clear statement describing the basis and the specific, scientific, or clinical rationale for the denial and instructions for requesting the clinical review criteria used.
  2. Reference to the evidence or documentation used as a basis for the decision, including whether any internal rule, guideline, protocol or similar criterion was relied upon in making the determination. In cases involving a denial of services, instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used.
  3. The provisions of the policy, contract or plan on which the determination is based.
  4. A clear statement that the notice is the final adverse determination.
  5. The health care plan's contact person and his/her telephone number.
  6. The member's coverage type.
  7. The name and full address of the health care plan's utilization review agent.
  8. The utilization review agent's contact person and his/her telephone number (for example the manager/responsible for the utilization review agent).
  9. A description of the health service that was denied, including, where applicable and available, the name of the facility and/or physician proposed to provide the treatment, and/or the developer/manufacturer of the health care service.
  10. A statement that the member may be eligible for an external appeal and the time frames for requesting the appeal.
  11. A statement that the member is entitled to receive, upon request and free of charge:
    • Reasonable access to and copies of all documents, records, and other information relevant to the claim.
    • A copy of each internal rule, guideline, protocol or similar criterion that was relied upon in making the determination on appeal.
    • A list of titles and qualifications ( including specialist of individuals participating in the appeal review)

12. The information supplied by the Superintendent of the New York State Department of Financial Services (NYSDFS) describing the external appeal process.
13. A statement that the claimant may have a right to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act (ERISA).
Blue Cross Blue Shield will maintain files on all appeal requests and decisions made. A member must receive standard appeal rights with the expedited internal appeal decision.

New York State (NYS) External Appeal

A member has the right to an external appeal of certain coverage determinations made by Blue Cross Blue Shield or our vendors. An external appeal is a request by a member to the New York State Department of Financial Services (NYSDFS) for an independent review by a third party known as an external review agent. External review agents are certified by New York State and may not have a prohibited affiliation with any health insurer, HMO, medical facility, health care provider, or member associated with an appeal.
The determination of the external review agent is binding for both the member and Blue Cross Blue Shield.

Eligibility for a NYS External Appeal

A member cannot request an external appeal unless we have issued a final adverse determination of an Internal Appeal Process. However, if Blue Cross Blue Shield disagrees with the admission of a provision or continuation of care by a facility for an enrollee diagnosed with advanced cancer (with no hope of reversal of primary disease and fewer than 60 days to live, as certified by the member's attending health care practitioner), Blue Cross Blue Shield shall initiate an expedited external appeal. Until a decision is rendered, the admission of, provision of, or continuation of care for the enrollee by the facility shall not be denied and Blue Cross Blue Shield shall provide continued coverage. If Blue Cross Blue Shield does not initiate an expedited external appeal, then Blue Cross Blue Shield shall reimburse that facility for services provided.

An expedited external review can occur concurrently with the internal appeals process for urgent care and ongoing treatment.

Blue Cross Blue Shield must include an application for an external appeal in the Final Appeal Determinations (FAD) to the member for all denials. Providers may obtain an application on the NYS Department of Financial Services website.

To be eligible for a NYS external appeal, the final adverse determination must be made on the basis that the service is not medically necessary, or the requested service is experimental or investigational, not materially different (out-of-network service request), training and experience (out-of-network referral request) or treatment of rare disease, as explained below;

1. Medical Necessity

The service or treatment is denied, in whole or in part, on the grounds that the service or treatment is not medically necessary and the service would otherwise be covered under the member's contract.

2. Experimental or Investigational

  • The service or treatment is denied on the basis that it is experimental or investigational; and
  • The member's attending practitioner has certified that the member has a life threatening or disabling condition or disease (i) for which standard treatment or services have been ineffectual or would be medically inappropriate, or (ii) for which there does not exist a more beneficial, standard service or treatment that is covered, or (iii) for which there exists a clinical trial; and
  • The member's attending practitioner (who must be a licensed, board-certified or board-eligible physician qualified to practice in the area of practice appropriate to treat the member's life threatening or disabling condition or disease) must have recommended either (i) a health service or treatment or procedure including a pharmaceutical product within the meaning of PHL 4900(5)(b)(B) that, based on at least two documents from the medical or scientific evidence, is likely to be more beneficial to the member than any covered, standard service or treatment; or (ii) a clinical trial for which the member is eligible. Any physician certification shall include a statement of the evidence relied upon by the physician in certifying his or her recommendation; and
  • The service or treatment would otherwise be covered except for the determination that it is experimental or investigational.

3. Out-of-Network Denials

There are two types of out-of-network denials that are eligible for external appeal:

  • Out-of-network service denial. The member's preauthorization request was denied because, while the service is not available in-network, the health plan recommends an alternate in-network service that it believes is not materially different from the out-of-network service.
  • Out-of-network referral denial. The member's out-of-network referral request was denied because the health plan has an in-network provider with the appropriate training and experience to meet the particular health care needs of the member.

4. Rare Disease

An enrollee with a life threatening condition who may require "rare disease treatment" may seek an external review for an adverse determination. Treatments of "rare diseases" would be approved, upon external review, if they contain all of the following;

  • A physician certification and evidence presented by the insured or the insured's physician
  • The treatment for the rare disease would be "likely to benefit" the enrollee, and
  • The benefit of such treatment outweighs the risk of said service or procedure.

Agreeing to a NYS External Appeal

Blue Cross Blue Shield members can request an external appeal even though we have not completed the initial appeal process. We are under no obligation to agree to this request. The Manager of Utilization Management Appeals, in conjunction with the Medical Director, considers all requests for waiving the initial appeal process on an individual basis.

If Blue Cross Blue Shield agrees to waive the internal process, Blue Cross Blue Shield must provide a written letter with information regarding filing an external appeal to member within 24 hours of the agreement to waive the Blue Cross Blue Shield internal appeal process.

NYS External Appeal Procedure

Members or their designees must send an external appeal application to the Department of Financial Services within four months from the date of the final adverse determination OR the waiver of the internal appeal process. Providers appealing a concurrent or retrospective adverse determination on their own behalf must request an external appeal within 60 days of the final adverse determination. If you do not send your application to the Department of Financial Services within the required timeframe (with an additional eight days allowed for mailing), you will not be eligible for an external appeal.

If a member files an external appeal, the member's claim will be reviewed by an External Appeal Agent whose decision will be binding on Blue Cross Blue Shield and the member.

Providers have their own right to an external appeal when health care services are denied concurrently or retrospectively, and must request an external appeal within 60 days.

For provider requested external appeals of concurrent adverse determinations: the provider is responsible for the cost if the external appeal is upheld, and both the provider and the plan are responsible for this cost (evenly divided) if the external appeal is upheld in part (partial overturn).

Administrative Services Only (ASO) External Appeal Process

The plan will provide notice of external appeal rights in the notice of the final internal adverse benefit determination. An ASO external appeal request application and an external appeal instruction sheet will be included in the notice. The member/ member's representative has four months from the receipt of the final internal adverse benefit determination to request an ASO external appeal.

Eligibility: An ASO external appeal is not requested unless we have issued a final adverse determination of an appeal. Following an expedited appeal, the plan cannot require members to use the standard internal appeal process before requesting an external appeal. To be eligible for an ASO external appeal, the final adverse determination must be made on the basis that the service is not medically necessary, or the requested service is experimental / investigational. External appeal rights do not exist for any other determinations, even if those other determinations affect coverage. A member and/or member's representative may request an external appeal.
The determination of the ASO external appeal agent is binding for both the member and the health plan.

Medical Claims Review

Medical Claims Review staff performs medical record reviews for medical appropriateness and adverse determination for the following types of claims routed from Claims Processing:

  • outpatient procedures and services
  • inpatient level of care
  • durable medical equipment
  • infusion therapy
  • professional claims for inpatient and outpatient services
  • all services where medical necessity determinations are to be made

The reviews are performed by health care professionals and administrative personnel, who determine:

  • contract eligibility, such as cosmetic procedures
  • medical appropriateness of services rendered
  • whether provider and member education is needed, which will generate a referral to the appropriate department


Timeframes for Processing Medical Claims/Post Service Claims

Complete Claims:
Blue Cross Blue Shield will render a decision (approval or denial) and provide written notice to the member or their authorized representative within 30 calendar days after receipt of the claim.

Incomplete Claims:
If Blue Cross Blue Shield is unable to make a decision due to failure to submit all necessary information, we may afford an extension of time to submit the missing information. If we allow the extension, we must provide notice within 30 calendar days after receipt of the claim of the specific missing information. We must allow 45 calendar days from the date of our notice to submit the missing information.

If we receive any of the information requested, we will render a decision and provide notice in writing within 15 calendar days after receipt of the information. If no information is submitted within the 45 calendar days, we must render a decision and provide notice within 15 calendar days after the end of the 45 day period.

New York State Prompt Pay Legislation requires that:

  • Decisions on claims for which adverse determinations are made are sent to the provider or member submitting the claim within 30 calendar days of claim receipt.
  • Claims submitted electronically must be paid within 30 days and paper or facsimile claim submissions must be paid within 45 days.
  • If medical records are to be requested, the request will be made within 30 calendar days of claim receipt.
  • The clock is reset to meet the above timeframes once medical records have been received.
  • A financial penalty is applied if claims are not processed within the above time frames.

Member Clinical Quality Complaints

To assess member experience with services, all member clinical complaints, and clinical complaint appeals, including behavioral health care, that involve quality of care/service, attitude, access to care, and quality of practitioner office site, are referred to the Utilization Management Quality Specialist (UMQS) for review investigation and/or resolution.

  • Complete investigation of the substance of the complaint including specific aspects of the clinical care involved is documented in a clinical management software tool. Pertinent medical records and practitioner/provider responses necessary to the investigation are included. Medical record documentation is reviewed with the Medical Director to reach a complaint determination of substantiated or not substantiated.
  • The member has a right to file a Level II Appeal if they do not agree with the initial determination of their initial complaint.

The identification and tracking of these clinical complaints are used for reporting and evidence necessary for internal and external auditors and regulatory requests.

Accreditation and Regulatory Compliance Unit

The purpose is to ensure that regulatory compliance for Utilization Management activities is adhered to both internally and with our delegated vendors.

Internal Compliance Oversight

Internal Utilization Management policies and procedures related to regulatory compliance issues are developed and updated at least on an annual basis or more frequently as warranted by new legislation standards. Oversight of letter development and updates to letters are a responsibility of this unit. Tools are developed for medical record review to incorporate all aspects of regulatory compliance activities. Medical records are audited on a regular basis to ensure compliance.

External Vendor Compliance Oversight

Our delegated vendors for Utilization Management activities are monitored through on-site visits by members of Utilization Management, Vendor Process Management, and others, as applicable. During the on-site review, the vendor's plan, policies and procedures, and UM activities are reviewed to ensure compliance with Article 49 of the NYS Health Law, CMS regulations, Federal Department of Labor (DOL), and NCQA standards. Medical necessity criteria are reviewed and approved by the Medical Management Clinical Committee (MMCC), or an ad hoc group of physician specialists, and the plan's Medical Director. Medical records are audited at least quarterly and more frequently if any deficiencies are noted. Vendor self-audits and more frequent medical record audits are conducted if necessary.

Utilization Data Tracking and Analysis

Utilization tracking is provided for the organization as a whole for all lines of business. The focus is:

  • Appropriate delivery of health care services to our members
  • Overall utilization tracking
  • Use of services (HEDIS)
  • Monitoring of services

Generally, both forms of data tracking involve the following activities:

  • Establish a baseline of medical care delivered to our members
  • Establishing historical utilization patterns for benchmarking purposes
  • Determining the level of statistical significance
  • Designing and implementing data-collection methodologies
  • Trend analysis
  • Compiling data into tables and graphs for easy reference
  • Determining a need for interventions
  • Analysis of implemented interventions
  • National benchmarks
  • Utilizing all available information technology

Focused Monitoring

The purpose of focused monitoring is to track the patient's outcome, frequencies of specific services and costs. Generally, these services either have a high potential for abuse or need to be followed to assess:

  • Medical appropriateness
  • Monitoring services specific to the individual safety needs and risks in conjunction with co-morbidity issues
  • Potential barriers to care
  • Potential under or over utilization by practice, and by product line
  • The utilization impact of pricing, benefit or other administrative changes

Appropriate interventions are implemented as opportunities are identified. The interventions are measured for effectiveness and the impact on the quality of care.

Overall Utilization Tracking

The purpose of overall utilization tracking is to establish norms that serve as the statistical baseline for determining shifts and trends in overall utilization which detail quality care delivered to our members.

Medical Policy Unit

The Medical Policy Unit researches, analyzes, and recommends Corporate Medical Protocol for all lines of business and effectively communicates each, both internally and externally (refer also to Section 8 - Corporate Medical Protocols).

Corporate Medical Protocol Development

Blue Cross Blue Shield will develop and monitor corporate medical policy, to evaluate the inclusion of new technologies and the new application of existing technologies. This includes medical and behavioral health procedures and devices. (Pharmaceutical policies are developed by the Clinical Pharmacy Services Unit; vaccine recommendations are provided in the Practice Guidelines; refer to Section 9 - Pharmacy and Section 11 - Practice Guidelines.) A decision to develop or revise Corporate Medical Protocol is made based on one or more of the following:

  • New technology/procedure/vaccine/device becomes available
  • A new application/indication is noted in literature for existing technology, procedure, vaccine, or device
  • Physician request
  • Annual review

Assessment criteria utilized for evaluating new technology and/or a new application to existing technology is contained in our Technology Assessment and Medically Necessary Services Protocol (refer to Medical Protocols on the provider website).