Early Intervention Program Utilization Review and External Appeal
Preauthorization and Concurrent and Retrospective Review
Insurers may undertake a review of services to be provided or that have been provided based on medical necessity. Such a review may occur before the services have begun, while they are ongoing, or after they have been received. For example, an insurer may require "preauthorization" of services before it will pay for them. Written decisions regarding pre-authorization of services (approval before services are given) must be communicated to the insured or the insuredís designee and the insuredís provider within three business days of receiving all necessary information. In the case of early intervention services, the county is deemed to "stand in the shoes of" the insured and also to serve as the provider. Therefore, the following discussion refers to the county in its role as subrogee of the insured and as provider of early intervention services.
Another type of review occurs when the insurer makes a decision regarding the extension or continuation of services already being provided, or the addition of services for an insured undergoing a continued course of treatment. The insurer must notify the county of such "concurrent" decisions within one business day of receiving necessary information in writing and by telephone. This notification must include the number of extended services approved, the new total of approved services, the date the new services are to begin and the next review date.
The third type of review involving medical necessity is "retrospective", occurring when the provider has already provided services. In this situation, the insurer must make a decision regarding such services within 30 days of receiving necessary information.
If a decision involving pre-authorization, concurrent review or retrospective review is made without consulting the provider (the county), the county may request a reconsideration of this decision. Except for retrospective reviews, the insurer must complete the reconsideration within one business day of its request. In addition, if the insurer fails to follow the above time frames, its decision may automatically be appealed.
If the insurer denies coverage for the services in each of the three situations discussed above (pre-authorization, concurrent review and retrospective review), the notice to the county must include the following:
- The reasons, including clinical rationale;
- Instructions on how to pursue an appeal;
- How to obtain the insurerís clinical review criteria;
- Additional information that might be needed on appeal.
These denials are known as "adverse determinations."
Once an adverse determination described above has been received, the county, acting in the place of the insured for pre-authorization and concurrent decisions, and as the provider in the case of a retrospective review, may appeal this decision.
There are two types of appeals, expedited and standard. The county would have a right to an expedited appeal it believes an immediate decision is needed or when continued or extended services, or additional services for an insured undergoing a continued course of treatment are involved.
In the case of an expedited appeal, the insurer must facilitate the resolution of this appeal by encouraging the sharing of information via the telephone or fax. The insurer must also provide access to the reviewer who made the clinical decision within one business day of receiving notice of this expedited appeal. The expedited appeal must be resolved within two business days of receiving information, and the insurer must notify the county within 24 hours of that resolution.
If the expedited appeal is resolved against the county, the insurer may provide access to a standard appeal process described below.
The county may file a standard appeal in writing or over the telephone within 45 days of receiving the adverse determination from the insurer. The insurer must acknowledge the appeal in writing within 15 days and make its decision within 60 days of receiving necessary information. The insurer must notify the insured and the provider, if relevant, within two business days.
In the case of both the expedited and the standard appeals described above, the insurer must provide a notice to the insureds and/or provider. The notice is known as a "final adverse determination" (FAD) and must include the following information:
- A clear statement of the basis for the decision, including clinical rationale.
- A clear statement that it is a FAD.
- Contact person and phone number.
- Information on external appeals.
It is important to be aware that the 45-day period for filing an external appeal, described below, begins after either an expedited or a standard appeal is filed. This 45-day deadline cannot be extended. Therefore, if an insured or a provider pursues a standard appeal after being denied after an expedited appeal, this 45-day period may run out.
If a claim is denied on an appeal described above, the insured, or the provider in the case of retrospective decisions for services that have already been provided, may pursue an outside appeal with an external review agent that has been certified by the New York State Department of Financial Services.
The insurer may charge a fee of up to $50.00 for an external appeal. This fee is refundable if the external appeal agent decides in favor of the insured or provider.
It is important to note that insureds, or providers, have forty-five days to file an external appeal from the date of the FAD. A form to request the external appeal may be downloaded from www.dfs.ny.gov. The insurer must also provide an external appeal application whenever the insured or provider is issued a final adverse determination based on reasons of medical necessity or when services are denied because they are considered experimental or investigational.
The external appeal agent may request additional information from the insured or the provider. This information should be sent immediately to the external appeal agent. Information can be submitted even when the external appeal agent has not requested specific information. The information must be submitted within 45 days from when the insurer made a final adverse determination or from when the insured and the insurer agree to waive the internal appeal.
There are two types of external appeals: expedited and standard. If a physician states that a delay in providing the service would pose an imminent or serious threat to the insuredís health, the external appeal shall be completed within three days of the request. The external appeal has 30 days from receipt of the request to make its decision and two business days to notify the insured and the insurer.