Utilization Review Standards

Utilization Review Standards (1) Responsibility for Obtaining Certification a. In the absence of any contractual agreement to the contrary, the enrollee is responsible for notifying the private review agent in a timely manner and obtaining certification for health care services, if required by the health benefit plan. A private review agent shall allow any licensed health care provider, or responsible patient representative, including a family member, to assist in fulfilling that responsibility. b. To ensure confidentiality, a private review agent must, when contacting a health care provider’s office or facility, or hospital, provide its certification number, the caller's name, and professional qualification to the designated utilization review representative in the health care provider’s office or facility, or hospital. (2) Information Upon Which Utilization Review is Conducted a. When conducting routine prospective and concurrent utilization review, the private review agent shall collect only the information necessary to certify the admission, procedure or treatment and length of stay. b. A private review agent should not routinely expect hospitals and physicians to supply numerically codified diagnoses or procedures. The private review agent may ask for such coding, since if it is known, its inclusion in the data collected increases the effectiveness of the communication. c. The private review agent shall not routinely request copies of medical records on all patients reviewed. During prospective and concurrent review, copies of medical records should only be required when a difficulty develops in certifying the medical necessity or appropriateness of the admission or extension of stay. In those cases, only the necessary or pertinent sections of the record should be required. d. Private review agents may request copies of medical records retrospectively for a number of purposes, including auditing the services provided, quality assurance, and evaluation of compliance with the terms of the health benefit plan or Utilization Review provisions. With the exception of the reviewing of records associated with an appeal or with an investigation of data discrepancies and unless otherwise provided for by contract or law, health care providers should be reimbursed the reasonable direct costs of duplicating requested records for retrospective review. e. Private review agents must comply with prior authorization standards as established by Miss. Code Ann. §§ 83-5-901 through 83-5-937. (3) Except as otherwise provided in these standards, a private review agent should limit its initial data requirements to the following elements: a. Patient Information i. Name ii. Address iii. Date of Birth iv. Sex v. Social Security Number or Patient ID Number vi. Name of Carrier or Plan vii. Plan ID Number b. Enrollee Information i. Name ii. Address iii. Social Security Number or Employee ID Number iv. Relation to Patient v. Employer vi. Health Benefit Plan vii. Group Number/Plan ID Number viii. Other Coverage Available (Workers’ Comp., Medicare, etc.) c. Attending Physician/Practitioner Information i. Name ii. Address iii. Phone Number iv. Degree v. Specialty/Certification Status vi. Tax ID or Other ID Number d. Diagnosis/Treatment Information i. Primary Diagnosis ii. Secondary Diagnosis iii. Proposed Procedure(s) or Treatment(s) iv. Surgical Assistant Requirement v. Anesthesia Requirement vi. Proposed Admission or Service Date(s) vii. Proposed Procedure Date viii. Proposed Length of Stay e. Clinical Information. Sufficient information for support of appropriateness and level of service proposed f. Facility Information i. Type (such as in-patient, out-patient, rehab, etc.) ii. Status (DRG exempt status, as needed) iii. Name iv. Address v. Phone Number vi. Tax ID or Other ID Number g. Concurrent (Continued Stay) Review Information i. Clinical Contact Person ii. Additional Days/Services Proposed iii. Reasons for Extension iv. Diagnosis (same/changed) v. Clinical Information (Sufficient to support, as above) h. Admissions to Facilities Other Than Acute Medical/Surgical Hospitals i. History of Present Illness ii. Patient Treatment Plan and Goals iii. Prognosis iv. Staff Qualifications v. 24 Hour Availability of Staff i. Compliance with prior authorization standards as established by Miss. Code Ann. §§ 83-5-901 through 83-5-937. (4) Special Situations a. Additional information may be required for other specific review functions such as discharge planning or catastrophic case management. Second opinion information may also be required, when applicable, sufficient to support benefit plan requirements. b. Information in addition to that described in this section may be requested by the private review agent or voluntarily submitted by the provider, when there is significant lack of agreement between the private review agent and health care provider regarding the appropriateness of certification during the review or appeal process. "Significant lack of agreement" means that the private review agent has: i. Tentatively determined, through its professional staff, that a service cannot be certified; ii. Referred the case to a physician for review; and iii. Talked to or attempted to talk to the attending physician for further information. c. A private review agent should share all clinical and demographic information on individual patients among its various divisions (e.g., certification, discharge planning, case management) to avoid duplicate requests for information from enrollee or providers. (5) Procedures For Review Determination a. Each private review agent shall have written procedures to ensure that reviews are conducted in a timely manner and as expeditiously as the enrollee’s condition requires. b. Each private review agent shall make utilization reviews of prior authorization after obtaining all necessary information within pursuant to the timeframes establish in Rule 19.09(6) for nonurgent circumstances and Rule 19.09(7) for urgent circumstances, unless a longer minimum time frame is required under federal law for the health insurance issuer and the health care service at issue. Collection of the necessary information may necessitate a discussion with the attending physician or, based on the requirements of the health benefit plan, may involve a completed second opinion review. c. A private review agent may review ongoing inpatient stays, but shall not routinely conduct daily review on all such stays. The frequency of the review for extension of the initial determination should vary based on the severity or complexity of the patient's condition or on necessary treatment and discharge planning activity. Routine concurrent review generally should not be necessary earlier than 24 hours prior to the lapse of the certified length of stay. d. Each private review agent shall have in place written procedures for providing notification of its determination regarding certification, recertification, or extensions of previously authorized length of stay in accordance with the following: i. When an initial determination is made to certify, notification shall be provided promptly either by telephone or in writing, via letter or electronic mail, to the attending physician. The notification shall be transmitted in writing to the hospital and attending physician, as well as to the enrollee or patient, within two working days. ii. A determination to certify resulting from concurrent review shall be transmitted to the attending physician by telephone or in writing within one working day of receipt of all information necessary to complete the review process or prior to the end of the current certified period. iii. If a private review agent transmits written confirmation of certification for continued hospitalization, that notification shall include the number of extended days, the new total number of days approved, and the date of admission. iv. When a determination is made not to certify a hospital or surgery facility admission or extension of a hospital stay or other service requiring review determination, the attending physician shall be notified by telephone within one working day and a written notification should be sent within one working day to the hospital, attending physician and the enrollee or patient. The written notification shall include the principal reason(s) for the determination and the way to initiate an appeal of the determination if the enrollee, patient, or their representative so chooses. Reasons for a determination not to certify shall include, among other things, the lack of adequate information to certify after a reasonable attempt has been made to contact the attending physician. (6) Utilization review of prior authorizations in nonurgent circumstances. If a health insurance issuer requires prior authorization of a health care service, the health insurance issuer must make an approval or adverse determination and notify the enrollee, the enrollee's health care professional, and the enrollee's health care provider of the approval or adverse determination as expeditiously as the enrollee's condition requires but no later than seven (7) calendar days after obtaining all necessary information to make the approval or adverse determination, unless a longer minimum time frame is required under federal law for the health insurance issuer and the health care service at issue. As used in this section, "necessary information" includes the results of any face-to-face clinical evaluation, second opinion or other clinical information that is directly applicable to the requested service that may be required. Notwithstanding the foregoing provisions of this section, health insurance issuers must comply with the requirements of Miss. Code Ann. § 83-9-6.3 to respond by two (2) business days for prior authorization requests for pharmaceutical services and products. (7) Utilization review of prior authorizations in urgent circumstances. a. If requested by a treating health care provider or health care professional for an enrollee, a health insurance issuer must render an approval or adverse determination concerning urgent health care services and notify the enrollee, the enrollee's health care professional and the enrollee's health care provider of that approval or adverse determination as expeditiously as the enrollee's condition requires but no later than forty-eight (48) hours after receiving all information needed to complete the review of the requested health care services, unless a longer minimum time frame is required under federal law for the health insurance issuer and the urgent health care service at issue. b. To facilitate the rendering of a prior authorization determination in conformance with this section, a health insurance issuer must establish a mechanism to ensure health care professionals have access to appropriately trained and licensed clinical personnel who have access to physicians for consultation, designated by the plan to make such determinations for prior authorization concerning urgent care services. (8) Notwithstanding language to the contrary elsewhere contained herein, if a licensed physician certifies in writing to an insurer within seventy-two (72) hours of an admission that the insured person admitted was in need of immediate hospital care for emergency services, such shall constitute a prima facie case of the medical necessity of the admission. To overcome this, the entity requesting the utilization review and/or the private review agent must show by clear and convincing evidence that the admitted person was not in need of immediate hospital care. (9) Private review agents shall have in place written procedures to address the failure of a health care provider, patient, or their representative to provide the necessary information for review. If the patient or provider will not release the necessary information to the Utilization Review Organization, the Utilization Review Organization may deny certification in accordance with its own policy or that of the health benefit plan.