Utilization Review Update

Durham Center AccessFebruary 23, 2011

Overview• Types of requests• Unable to process• Incomplete requests• Changes to submission time

requirements• Scenarios that could effect service

delivery

Types of Requests• Initial request: request for a service the

recipient was not authorized to receive on the day immediately preceding the UR vendor’s receipt of the request

• Reauthorization or continuing/concurrent request: request for a service required to be authorized for that recipient on the day immediately preceding the date of the UR vendor’s receipt of the request

Types of Requests• Prospective request: generally request

a service that consumers not currently receiving

• Concurrent request: generally requests made for a consumer to continue receiving a previously-authorized service

Reminders• Prior approval of Medicaid services

require full clinical documentation to demonstrate medical necessity

• Supplement previous information with recent clinical information to document medical necessity if necessaryo recent evaluation reports from clinicianso recent treatment recordso letters signed by treating clinicians

Unable to Process• Recipient name and address, MID

number, date of birth• Identification of service requested or

procedure code• Provider name/NPI/Provider number of

provider to perform service or procedure

• All signatures on forms required by law

Unable to Process• Date requested service to begin or be

performed• Documents or forms required by State

or federal statuteExample: Psychiatric assessment and discharge plan must be submitted as part of any request for Child Level III and IV Residential Services

Unable to Process• No review for medical necessity will

occur when request returned “Unable to Process” o new request required with start date no

earlier than date of the resubmission of the request

o “Unable to Process” notice does not include appeal rights

Incomplete Requests• Requests for prior approval must use

forms and fields required by applicable clinical coverage policy and vendor

• Requests must include all necessary attachments (e.g. person centered plans) complete

• Requests without minimum required clinical coverage information are incomplete

Examples of Incomplete Requests• Signature on PCP missing

• Credentials not included with signature• Checked boxes not checked• Dates missing on signatures• Discharge plan missing• SOC (System of Care) Coordinator

signature missing• Risk assessment missing

Examples of Incomplete Requests• Attestation missing in change of

provider request• PCP not properly filled out

Pending• The Durham Center will no longer pend

requests and ask providers for required attachments that are missing

Pending• Competed requests requiring

additional information to determine medical necessity will be pended and information requestedo provider receives written notification of

what additional information neededo if requested documentation not received

within 10 business days, decision will be based on available information

New Requirement• Beginning 00/00/11 requests for

re-authorization or continuation of services must be made at least 10 calendar days prior to end of current authorization period

• If request submitted properly but TDC decision not made prior to end of current authorization period, retroactive authorization will be entered when vendor decision is made

New Requirement• Does not apply to “Unable to Process”

requestso will not serve as a “placeholder” for

purposes of the 10-day requirement

• Requests for CAP, inpatient, or emergent services not subject to 10-day requiremento must be submitted by current policyo if submitted before expiration of

authorization period, services continue without interruption

Reauthorization• If provider does not request

reauthorization at least 10 calendar days prior to end of current authorization period, there may be a break in authorization

Example: Recipient authorized to receive 8 units of service a week June 1-August 30. If provider believes it is medically necessary for service to continue beyond August 30, request for prior approval must be submitted by 10 calendar days prior to August 30 (August 21) for services to continue without interruption.

Reauthorization• Continue to provide services beyond

the end of the authorization period if reauthorization request was timely

• Providers paid for services provided when the authorization request is timely as specified by these instructions

• Should TDC fail to authorize services as specified by these instructions, contact the DMA Appeals Unit at (919) 855-4260

Reauthorization• If request submitted at least 10

calendar days prior to end of current authorization period and request approved, no break in service and service authorized beginning on the first day after the end of the authorization period

Example: Recipient authorized to receive 8 units of service a week June 1-August 30. Request for prior approval of 8 units per week for additional 90 days submitted on August 15. TDC approves request on September 4. Authorization will be retroactive to September 1.

Reauthorization• Requests for prior approval to continue

authorization of service recipient currently receiving less than 10 calendar days prior to the end of the authorization period will, if possible, be processed within The Durham Center’s required turnaround time

• If approved, will be authorized beginning on date of decision, not backdated to account for late requests

ReauthorizationExample: Recipient authorized to receive 8 units of service a week June 1-August 30. Request for prior approval of 8 units per week for additional 90 days submitted on August 28. TDC approves request on September 4. Authorization for 8 units per week entered into the system on September 4 for 90 days.

• Service is not authorized from September 1-3.

Reauthorization• Requests for prior approval to continue

authorization of a current service received less than 10 calendar days prior to the end of authorization period

• If denied or reduced, authorization at prior level of service entered for 10 days beginning date of decision

• If recipient files timely appeal, authorization will continue through the appeal period

ReauthorizationExample: Recipient authorized to receive 8 units of service a week June 1-August 30. Request for prior approval of 8 units per week for additional 90 days submitted on August 28. TDC approves request on September 4. Authorization for 8 units per week entered into system effective September 4 for 10 days.

• Authorization for 4 units per week for 80 days entered effective September 15.

Reauthorization• If appeal is requested within 10 calendar

days of the decision, authorization for 8 units must continue without further interruption.

• If an appeal is requested more than 10 calendar days after date of notice but within 30 days, MOS must be entered at 8 units per month effective with date of appeal and continuing until a final agency decision.

• Service is not authorized from September 1-3.

If UM Response Not Timely• If no decision within 15 business days

on request to continue authorization of service, on day 16 TDC must enter authorization for service to continue at prior level until effective date of its decision on the request

• Applies as long as the request submitted before authorization period expired

If UM Response Not TimelyExample: Recipient authorized to receive 8 units of service a week June 1-August 30. Request for prior approval of 8 units per week of service for additional 90 days submitted on August 27. TDC unable to issue decision by September 20 (15th business day after August 27).

• Authorization for 8 units per week entered on September 21 to continue until 10 days after decision issued on the request.

• Service is not be authorized from September 1-20.

Reauthorization• If request submitted more than one day

after end of current authorization period, request treated as an initial request

ReauthorizationExample: 20 hours per month of service authorized through May 31. Provider requests reauthorization of 20 hours per month on June 2. TDC treats request for services as initial request.

• If TDC approves re-authorization, payment for service stops May 31. Authorization resumes effective date of notice because re-authorization not requested prior to end of current authorization period.

Reauthorization• If TDC reduces re-authorization request,

payment stops on May 31. Authorization for service at new level begins effective date of notice at amount approved by TDC.

• If appeal requested, services authorized at new level pending appeal because re-authorization not requested prior to the end of current authorization period.

Reauthorization• If TDC denies re-authorization request,

payment stops on May 31. No authorization for services pending appeal because re-authorization not requested prior to end of current authorization period.

Final Reminders• Requests returned as Unable to

Process do not afford appeal rights to consumer

• Requests returned to provider as Incomplete do afford appeal rights to consumer

• Appeal Form is only sent to the consumer

• Notices mailed to provider via first class mail

• Notices mailed to consumers via UPS as trackable mail