Current through 2024-13, March 27, 2024
In addition to the requirements of Title 24-A, Chapter 34,
any health carrier that provides or performs utilization review services, and
any designee of the health carrier or URE that performs utilization review
functions on the carrier's behalf, is subject to the requirements of this
section. The requirements of this section are applicable to all "adverse health
care treatment decisions" rendered by or on behalf of "carriers."
A.
Corporate Oversight of Utilization
Review Program
A health carrier shall be responsible for monitoring all
utilization review activities carried out by or on its behalf, and for
compliance with the requirements of this. The health carrier shall also ensure
that, consistent with the requirements of Title
24-A M.R.S.A.
§4304(1), appropriate
personnel have operational responsibility for the conduct of the health
carrier's utilization review program.
B.
Contracting
Whenever a health carrier contracts to have a URE perform
the utilization review functions required by this rule, the Superintendent
shall hold the health carrier responsible for monitoring the activities of the
utilization review entity with which it contracts and for ensuring that the
requirements of this rule are met.
C.
Written Utilization Review
Program
A health carrier that provides or performs utilization
review shall implement a written utilization review program that, consistent
with the requirements of Title
24-A M.R.S.A.
§2771(3) and this rule,
shall comprehensively describe all utilization review activities and
procedures, both delegated and non-delegated, applicable to any of its health
plans. The utilization review program must be consistent with the requirements
of this section.
D.
Operational Requirements
1) A
utilization review program shall use documented clinical review criteria that
are based on published sound clinical evidence and which are evaluated
periodically to assure ongoing efficacy. A health carrier or the carrier's
designated URE may develop its own clinical review criteria or may purchase or
license clinical review criteria from qualified vendors. Upon request, a health
carrier or the carrier's designated URE shall make available its clinical
review criteria to the Superintendent and the Commissioner of the Department of
Human Services.
2) Qualified health
care professionals shall administer the utilization review program and oversee
review decisions. A clinical peer shall evaluate the clinical appropriateness
of adverse health care treatment decisions.
3) A health carrier or the carrier's
designated URE shall issue utilization review decisions in a timely manner
pursuant to the requirements of subsections F, G, G-1, and H.
a) A health carrier or the carrier's
designated URE shall obtain all information required to make a utilization
review decision, including pertinent clinical information.
b) A health carrier or the carrier's
designated URE shall have a process to ensure that utilization reviewers apply
clinical review criteria consistently.
4) A health carrier or the carrier's
designated URE shall routinely assess the effectiveness and efficiency of its
utilization review program.
5) A
health carrier's or the carrier's designated URE's data systems shall be
sufficient to support utilization review program activities and to generate
management reports to enable the health carrier or the carrier's designated URE
to monitor and manage health care services effectively.
6) If a health carrier delegates any
utilization review activities to a URE, the health carrier shall maintain
adequate oversight, which shall include:
a) A
written description of the URE's activities and responsibilities, including
reporting requirements;
b) Evidence
of formal approval of the URE program by the health carrier; and
c) A process by which the health carrier
evaluates the performance of the URE.
7) A health carrier or the carrier's
designated URE shall provide covered persons and participating providers with
access to its review staff by a toll-free number or collect call phone line.
Telephone lines must be adequately staffed to provide providers and covered
persons ready access to staff performing utilization review
functions.
8) When conducting
utilization review, the health carrier or the carrier's designated URE shall
collect only the information necessary to certify the admission, procedure or
treatment, length of stay, frequency and duration of services. The requirements
of this subsection shall not be construed to prevent a carrier from collecting
data for quality assurance purposes.
9) Compensation to persons providing
utilization review services for a health carrier or the carrier's designated
URE may not be based on the quantity of adverse health care treatment decisions
rendered, or otherwise include incentives for reviewers to render inappropriate
review decisions.
E.
Procedures for Review Decisions
1) A health carrier or the carrier's
designated URE shall maintain written procedures for making utilization review,
experimental/investigational treatment and preexisting condition decisions, and
for notifying covered persons and providers acting on behalf of covered persons
of its decisions. For purposes of this subsection, the term "covered person"
includes the representative of a covered person. Prior to release of medical
information to a representative of a covered person, a health carrier or the
carrier's designated URE may require execution of an appropriate release
authorizing the representative's access to that information. Consistent with
the requirements of Title
24-A M.R.S.A.
§4304(2), notification
requirements under this subsection are satisfied by written notification
postmarked within the time limit specified.
2) For initial determinations not involving
exigent circumstances, a health carrier or the carrier's designated URE shall
make the determination (whether adverse or not) and so notify the covered
person and his or her provider within 72 hours or 2 businessdays, whichever is
less, in accordance with the following standards:
a) If the carrier or the carrier's designated
URE responds with a request for additional information, the carrier shall make
a determination and so notify the covered person and his or her provider within
72 hours or 2 business days, whichever is less, after receiving the requested
information.
b) If the carrier or
the carrier's designated URE responds that outside consultation is necessary
before making a determination, the carrier shall make a determination within 72
hours or 2 business days, whichever is less, from the time of the carrier's
initial response.
c) If a carrier
or the carrier's designated URE does not grant or deny a request within the
timeframes required, the request is granted.
d) A provider shall make best efforts to
provide all necessary information to evaluate a request, and a carrier shall
make best efforts to limit requests for additional information. A carrier or
the carrier's designated URE shall make a good faith effort to obtain all
necessary information expeditiously, and is responsible for expeditious
retrieval of necessary information in the possession of a person with whom the
health carrier contracts. A health carrier or the carrier's designated URE
shall comply with the notification requirements of Title
24-A M.R.S.A.
§4304(2). For purposes
of this section, "necessary information" includes the results of any
face-to-face clinical evaluation or second opinion that may be
required.
3) When
exigent circumstances exist, a health carrier or the carrier's designated URE
shall make the determination (whether adverse or not) and so notify the covered
person and his or her provider within 24 hours after receiving the
request.
4) For concurrent review
determinations, a health carrier or the carrier's designated URE shall make the
determination within one working day after obtaining all necessary information.
a) In the case of a determination to certify
an extended stay or additional services, the carrier or the carrier's
designated URE shall so notify the covered person and the provider rendering
the service within one working day. 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.
b) In the case of an
adverse benefit determination, the carrier or the carrier's designated URE
shall so notify the covered person and the provider rendering the service
within one working day. The service shall be continued without liability to the
covered person until the covered person has been notified of the
determination.
5) For
retrospective review decisions, a health carrier or the carrier's designated
URE shall make the decision within 30 days after receiving all necessary
information.
a) In the case of a
certification, the carrier or the carrier's designated URE may notify in
writing the covered person and the provider rendering the service.
b) In the case of an adverse health care
treatment decision, the carrier or the carrier's designated URE shall, within 5
working days after making the adverse decision, notify in writing the provider
rendering the service and the covered person. A health carrier or the carrier's
designated URE shall not without adequate written notice to the covered person
prior to his or her receipt of previously authorized services render an adverse
decision with regard to health care services authorized pursuant to prospective
review, except where fraudulent or materially incorrect information was
provided to the carrier at the time prior approval was granted, and the
information was relied upon by the carrier in rendering its approval.
6) A health carrier shall provide
written notification of any adverse health care treatment decision, which shall
include:
a) the principal reason or reasons
for the decision;
b) reference to
the specific plan provisions on which the decision is based;
c) information sufficient to identify the
claim involved (including the date of service, the health care provider, and
the claim amount if applicable), and a statement that the diagnosis code and
its corresponding meaning, and the treatment code and its corresponding
meaning, will be provided upon request;
d) a description of any additional material
or information necessary for the covered person to perfect the claim and an
explanation as to why such material or information is necessary;
e) the instructions and time limits for
initiating an appeal or reconsideration of the decision;
f) if the adverse health care treatment
decision is based on a medical necessity or experimental treatment or similar
exclusion or limit, either an explanation of the scientific or clinical
judgment for the decision, applying the terms of the plan to the claimant's
medical circumstances, or a statement that such an explanation will be provided
free of charge upon request;
g) if
an internal rule, guideline, protocol, or other similar criterion was relied
upon in making the adverse health care treatment decision, either the specific
rule, guideline, protocol, or other similar criterion; or a statement referring
to the rule, guideline, protocol, or other similar criterion that was relied
upon in making the adverse decision and explaining that a copy will be provided
free of charge to the covered person upon request;
h) a phone number the covered person may call
for information on and assistance with initiating an appeal or reconsideration
and/or requesting clinical rationale and review criteria;
i) a description of the expedited review
process applicable to claims involving exigent circumstances;
j) the availability of any applicable office
of health insurance consumer assistance or ombudsman established under the
federal Affordable Care Act;
k)
notice of the right to file a complaint with the Bureau of Insurance after
exhausting any appeals under a carrier's internal review process. In addition,
an explanation of benefits (EOB) must comply with the requirements of
24-A M.R.S.A.
§4303(13) and any rules
adopted pursuant thereto; and l) any other information required pursuant to the
federal Affordable Care Act.
7) The carrier or the carrier's designated
URE shall respond expeditiously to requests for information.
8) A health carrier or the carrier's
designated URE shall have written procedures to address the failure or
inability of a provider or a covered person to provide all clinically relevant,
necessary information for review. In cases where the provider or a covered
person will not release necessary information, the health carrier or the
carrier's designated URE may deny certification.
F.
Requests for Reconsideration
1) In a case involving an initial health care
treatment decision or a concurrent review decision, a health carrier or the
carrier's designated URE shall give the provider rendering the service an
opportunity to request by telephone, fax, electronically, or in writing on
behalf of the covered person a reconsideration of an adverse decision by the
reviewer making the adverse decision.
2) The reconsideration shall occur within one
working day after the receipt of the request and shall be conducted between the
provider rendering the service and the reviewer who made the adverse health
care treatment decision, or between the provider rendering the service and a
clinical peer of that provider, designated by the reviewer, if the reviewer who
made the adverse decision cannot be available within one working day.
3) If the reconsideration process does not
resolve the difference of opinion, the adverse health care treatment decision
may be appealed by the covered person or the provider on behalf of the covered
person. Reconsideration is not a prerequisite to a standard appeal or an
expedited appeal of an adverse decision.
G.
Appeals of Adverse Health Care
Treatment Decisions
For purposes of this section, the term "covered person"
includes the representative of a covered person.
1)
Standard Appeals
a) A health carrier or the carrier's
designated URE shall establish written procedures for a standard appeal of an
adverse health care treatment decision. HMO enrollees shall retain the right to
pursue an appeal directly with the HMO. Appeal procedures shall be available to
the covered person and to the provider acting on behalf of the covered person.
i) The carrier must allow the covered person
to review the claim file and to present evidence and testimony as part of the
internal appeals process.
ii) The
carrier must provide the covered person, free of charge, with any new or
additional evidence considered, relied upon, or generated by the carrier (or at
the direction of the carrier) in connection with the claim; such evidence must
be provided as soon as possible and sufficiently in advance of the decision to
give the covered person a reasonable opportunity to respond.
iii) Before a carrier can issue a final
internal adverse benefit determination based on a new or additional rationale,
the covered person must be provided with the rationale, free of charge,
sufficiently in advance of the decision to give the covered person a reasonable
opportunity to respond.
iv) The
health carrier must provide the covered person the name, address, and telephone
number of a person designated to coordinate the appeal on behalf of the health
carrier.
v) The health carrier
must make the rights in this subparagraph known to the covered person within 3
working days after receiving an appeal.
b) An appeal of an adverse health care
treatment decision, except for a rescission determination or an initial
coverage eligibility determination, shall be evaluated by an appropriate
clinical peer or peers of the treating provider. The clinical peer/s shall not
have been involved in the initial adverse determination, unless additional
information not previously considered during the initial review is provided on
appeal. The clinical peer may not be a subordinate of a clinical peer involved
in the prior decision.
c) For
standard appeals, the health carrier or the carrier's designated URE shall
notify in writing both the covered person and the attending or ordering
provider of the decision within 30 days following the request for an appeal.
Additional time is permitted where the carrier or the carrier's designated URE
can establish the 30-day time frame cannot reasonably be met due to the
carrier's or designee's inability to obtain necessary information from a person
or entity not affiliated with or under contract with the carrier. The carrier
or the carrier's designated URE, shall provide written notice of the delay to
the covered person and the attending or ordering provider. The notice shall
explain the reasons for the delay. In such instances, decisions must be issued
within 30 days after the carrier's or designee's receipt of all necessary
information. An adverse health care treatment appeal decision shall contain:
i) The names, titles and qualifying
credentials of the person or persons evaluating the appeal;
ii) A statement of the reviewers'
understanding of the reason for the covered person's request for an appeal;
iii) Reference to the specific
plan provisions upon which the decision is based.
iv) The reviewers' decision in clear terms
and the clinical rationale in sufficient detail for the covered person to
respond further to the health carrier's position;
v) A reference to the evidence or
documentation used as the basis for the decision, including the clinical review
criteria used to make the determination. The decision shall include
instructions for requesting copies, free of charge, of information relevant to
the claim, including any referenced evidence, documentation or clinical review
criteria not previously provided to the covered person. Where a covered person
had previously submitted a written request for the clinical review criteria
relied upon by the health carrier or the carrier's designated URE in rendering
its initial adverse decision, the decision shall include copies of any
additional clinical review criteria utilized in arriving at the decision.
vi) If an internal rule,
guideline, protocol, or other similar criterion was relied upon in making the
adverse benefit decision, either the specific rule, guideline, protocol, or
other similar criterion; or a statement referring to the rule, guideline,
protocol, or other similar criterion that was relied upon in making the adverse
decision and explaining that a copy will be provided free of charge to the
covered person upon request.
vii)
Notice of any subsequent appeal rights, and the procedure and time limitation
for exercising those rights. Notice of external review rights must be provided
to the enrollee as required by
24-A M.R.S.A.
§4312(3). A description
of the process for submitting a written request for second level appeal must
include the rights specified in subsection G-1.
viii) Notice of the availability of any
applicable office of health insurance consumer assistance or ombudsman
established under the federal Affordable Care Act.
ix) Notice of the covered person's right to
contact the Superintendent's office. The notice shall contain the toll free
telephone number, website address, and mailing address of the Bureau of
Insurance.
x) Any other
information required pursuant to the federal Affordable Care
Act.
2)
Expedited Appeals
A health carrier or the carrier's designated URE shall
establish written procedures for the expedited review of an adverse health care
treatment decision involving a situation where the time frame of the standard
review procedures set forth in paragraph 1 would seriously jeopardize the life
or health of a covered person or would jeopardize the covered person's ability
to regain maximum function. An expedited appeal shall be available to, and may
be initiated by, the covered person or the provider acting on behalf of the
covered person.
a) An expedited appeal
of an adverse health care treatment decision, except for a rescission
determination or an initial coverage eligibility determination, shall be
evaluated by an appropriate clinical peer or peers of the treating provider.
The clinical peer/s shall not have been involved in the initial adverse health
care treatment decision, unless additional information not previously
considered during the initial review is provided on appeal. The clinical peer
may not be a subordinate of a clinical peer involved in the prior
decision.
b) A health carrier, or
the carrier's designated URE shall provide expedited review to all requests
concerning an admission, availability of care, continued stay or health care
service for a covered person who has received emergency services but has not
been discharged from a facility.
c)
In an expedited review, all necessary information, including the health
carrier's or the carrier's designated URE's decision, shall be transmitted
between the health carrier or the carrier's designated URE and the covered
person or the provider acting on behalf of the covered person by telephone,
facsimile, electronic means or the most expeditious method available.
d) In an expedited review, a health carrier
or the carrier's designated URE shall make a decision and notify the covered
person and the provider acting on behalf of the covered person via telephone as
expeditiously as the covered person's medical condition requires, but in no
event more than 72 hours after the review is initiated. If the expedited review
is a concurrent review determination of emergency services under subsection H
of this section or of an initially authorized admission or course of treatment,
the service shall be continued without liability to the covered person until
the covered person has been notified of the decision.
e) If the initial notification was not in
writing, a health carrier or the carrier's designated URE shall provide written
confirmation of its decision concerning an expedited review within 2 working
days after providing notification of that decision. An adverse decision shall
contain the provisions specified in subparagraph 1(c) above.
A health carrier or the carrier's designated URE is not
required to provide an expedited review for retrospective adverse health care
treatment decisions.
G-1.
Second Level Appeals of Adverse
Health Care Treatment Decisions
1) A
health carrier that subjects benefit decisions to utilization review or offers
managed care plans shall provide the opportunity for a second level appeal to
covered persons who are dissatisfied with a first level appeal decision. The
covered person requesting a second level appeal has the right to appear in
person before authorized representatives of the health carrier, and shall be
provided adequate notice of that option by the carrier. Persons covered under
individual health insurance plans must be notified of the right to request an
external review without exhausting the carrier's second level appeal process.
The same notice may be given to persons covered under group plans if the
carrier permits them to bypass the second level of appeal. The health carrier's
designated URE may fulfill the requirements of this subsection on the carrier's
behalf, except that a person covered under an HMO plan may exercise his or her
right to pursue the appeal directly to the HMO.
2) The carrier shall appoint a panel for each
second level appeal, which shall include one or more panelists who are
disinterested clinical peers of the treating provider. For purposes of this
paragraph, a provider is disinterested if he or she was not involved in the
prior decision, is not a subordinate of a panelist involved in the prior
decision, and has no financial or other personal interest in the outcome of the
review. A second level appeal decision adverse to the covered person must have
the concurrence of a majority of the disinterested clinical peers on the
panel.
3) Whenever a covered person
has requested the opportunity to appear in person before authorized
representatives of the health carrier, a health carrier's procedures for
conducting a second level panel review shall include the following:
a) The review panel shall schedule and hold a
review meeting within 45 days after receiving a request from a covered person
for a second level review. The review meeting shall be held during regular
business hours at a location reasonably accessible to the covered person. The
health carrier shall offer the covered person the opportunity to communicate
with the review panel, at the health carrier's expense, by conference call,
video conferencing, or other appropriate technology. The covered person shall
be notified in writing at least 15 days in advance of the review date. The
health carrier shall not unreasonably deny a request for postponement of the
review made by a covered person.
b)
Upon the request of a covered person, a health carrier shall provide to the
covered person all relevant information that is not confidential and privileged
from disclosure to the covered person.
c) A covered person has the right to:
i) Attend the second level review;
ii) Present his or her case to the review
panel;
iii) Submit supporting
material both before and at the review meeting;
iv) Ask questions of any representative of
the health carrier;
v) Be assisted
or represented by a person of his or her choice; and
vi) Obtain his or her medical file and
information relevant to the appeal free of charge upon
request.
d) If the health
carrier will have an attorney present to argue its case against the covered
person, the carrier shall so notify the covered person at least 15 days in
advance of the review, and shall advise the covered person of his or her right
to obtain legal representation.
e)
The covered person's right to a fair review shall not be made conditional on
the covered person's appearance at the review.
f) The review panel shall issue a written
decision to the covered person within 5 working days after completing the
review meeting. A decision adverse to the covered person shall include the
requirements set forth in subparagraph 8(G)(1)(c).
H.
Emergency Services
When conducting utilization review or making a benefit
determination for emergency services:
1) A health carrier shall cover emergency
services necessary to screen and stabilize a covered person, and shall not
require prior authorization of such services if a prudent layperson acting
reasonably would have believed that an emergency medical condition existed. For
purposes of this subsection, the terms "screening" and "stabilize" shall be
interpreted consistent with Section 1867 of the Social Security Act at
42
U.S.C. §
1395dd. With respect to care
obtained from a non-contracting provider within the service area of a managed
care plan, a health carrier shall cover emergency services necessary to screen
and stabilize a covered person and shall not require prior authorization of the
services if a prudent layperson would have reasonably believed that use of a
contracting provider would result in a delay that would worsen the emergency,
or if a provision of federal, state or local law requires the use of a specific
provider.
2) A health carrier shall
cover emergency services if the health carrier, acting through a participating
provider or other authorized representative, has authorized the provision of
emergency services.
3) If a
participating provider or other authorized representative of a health carrier
authorizes emergency services, the health carrier shall not subsequently
retract its authorization after the emergency services have been provided, or
reduce payment for an item or service furnished in reliance on approval, unless
the approval was based on fraudulent or materially incorrect
information.
4) Coverage of
emergency services shall be subject to applicable copayments, coinsurance and
deductibles.
5) For immediately
required post-evaluation or post-stabilization services, a health carrier shall
provide access to a representative authorized to review the requested services
and determine medical necessity 24 hours a day, 7 days a week, or services
shall be provided without liability to the covered person until such time as an
authorized representative is available.
6) Before a carrier denies benefits or
reduces payment for an emergency service based on a determination of the
absence of an emergency medical condition or a determination that a lower level
of care was needed, the carrier shall conduct a utilization review done by a
board-certified emergency physician who is licensed in this State, including a
review of the covered person's medical record related to the emergency medical
condition subject to dispute. If a carrier requests records related to a
potential denial of benefits or payment reduction when emergency services were
furnished to a covered person, a provider has an affirmative duty to respond to
the carrier in a timely manner. This paragraph does not apply when a carrier
makes a reduction in payment for health care services based on a contractually
agreed upon adjustment.
I.
Disclosure Requirements
1) A health carrier shall include a clear and
reasonably comprehensive description of its utilization review procedures,
including the procedures for obtaining review of adverse benefit
determinations, and a statement of rights and responsibilities of covered
persons with respect to those procedures in the certificate of coverage or
member handbook provided to covered persons. The statement of rights shall
disclose the member's right to request in writing and receive copies of any
clinical review criteria utilized in arriving at any adverse health care
treatment decision pertaining to the member.
2) A health carrier shall include a summary
of its utilization review procedures in materials intended for prospective
covered persons. Health carriers who offer managed care plans shall include
utilization review procedure summaries in materials intended for prospective
network providers.
3) A health
carrier requiring enrollees to initiate utilization review shall print on its
membership cards a toll-free telephone number to call for utilization review
decisions.