The file should be scored "Yes.” A person making the appeal decision is different from, and not subordinate to, an automated system.
The criterion referenced must be identifiable by name and must be specific to an organization or source (e.g., ABC PBM’s Criteria for Treatment of Hypothyroidism with Synthroid or CriteriaCompany Inc.’s Guidelines for Wound Treatment). If it is clear that the criterion is attributable to the organization, it is acceptable to state “our Criteria for XXX” (e.g., our Criteria for Treating High Cholesterol with Lipitor).
Note: This also applies to Element E and Element H in HPA and Element E in UM-CR.
Yes. Automatic credit is available for an Interim Survey if the organization delegates to an NCQA-Accredited/Certified health plan, MBHO or UM-CR. The delegate’s Accreditation/Certification Survey must include the specific elements or factors for which the organization seeks automatic credit. The organization is responsible for determining if delegated activities are covered in the scope of the delegate’s NCQA review.
No. Organizations are not required to include reviewer names on the decision letter or verbally inform members that the information is available upon request. This language will be removed from UM 9, Element D in the March Policy update.
Please note this requirement remains in UM 8, Element A.
No. Organizations may not use mass communication for this element. Organizations have three options to notify practitioners of the opportunity to discuss a denial:
1. In the denial notification (included in the denial file).
2. By telephone (time and date of the denial included in the denial file).
3. In materials sent to the treating practitioner, informing the practitioner of the opportunity to discuss a specific denial with a reviewer (evidence that the practitioner was notified that a physician or other reviewer is available to discuss the denial included in the denial file).
The following denials (rejections) are included in the scope of UM 4, Element H (UM 4, Element F in MBHO and UM-CR):
* Inaccurately filed claims that were rejected because of incorrect dosage or quantity may be considered pending until a decision is made. If the request is denied, the claim is included in the scope of UM 4, Element H.