Reasonable Effort Policy

  • Policy is also available in Portable Document Format (PDF)

Purpose:
To provide guidance for Managed Care Organizations (MCOs) and their delegated Utilization Review Agents (URA) on what constitutes reasonable efforts when providing enrollees or their designees and providers phone notice, which may be made by electronic means, as required under law and regulation.

Authority:
N.Y. Public Health Law Article 49 and Section 4408-a; 42 CFR 438.210(d) and 438.408(c)(2)(i); Medicaid Managed Care/Family Health Plus/HIV Special Needs Plan/Health and Recovery Plan Model Contract (Model Contract) Appendix F; 42 CFR 457.1230(d) and 457.1260(e)(1); Child Health Plus (CHPlus) Subscriber Contract/Member Handbook Section 27; Medicaid Advantage Plus (MAP) Model Contract Appendix F; Managed Long Term Care Partial Capitation Contract Appendix K ; CMS PACE Manual § 20.2.

Policy:
MCOs, and URAs (where applicable), must establish protocols for documenting that they have made a reasonable effort to notify enrollees or their designees and providers, of determinations by phone. Such protocols must be compliant with confidentiality requirements set forth by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and New York State.

Acceptable phone notification occurs when:

  • The MCO or URA makes phone contact with the enrollee or their designee, and the provider or staff person in the provider’s office (provider’s representative) and communicates the approval, partial approval or denial of the requested service; or
  • If the provider is acting as the enrollee’s designee, the MCO or URA makes phone contact with the provider or provider’s representative, and communicates the approval, partial approval, or denial of the requested services; or
  • The MCO or URA has made a reasonable effort to make phone contact with the enrollee/designee and/or the requesting provider/provider’s representative, in accordance with this policy, but has not successfully made phone contact; or
  • The MCO or URA provides the notification by electronic means in accordance with the electronic noticing guidance after obtaining the enrollee’s preference for notification.
    • If the MCO receives indication that the electronic notification was undeliverable, the MCO shall provide the required phone notice and/or send the required written notification in compliance with applicable law or regulation.

"Phone contact" means an MCO or URA representative or interactive automatic voice messaging system: 1) directly communicates with the enrollee/designee and/or the provider/provider’s representative, or 2) leaves a HIPAA compliant voicemail for the enrollee/designee and/or provider/provider’s representative.

Reasonable Effort is defined as:

At least two unsuccessful attempts, by phone, to advise an enrollee or their designee, and/or a provider/provider’s representative of the determination. An unsuccessful attempt is defined as a call answered by someone other than the enrollee/designee or provider/provider’s representative; phone line is busy; or the call is unanswered after ten rings.

If the first call is unsuccessful, a second call must be attempted no sooner than one hour after the first call to be considered a new attempt.

If the call goes to voicemail and the MCO or URA chooses to leave a message, the caller/interactive automatic voice messaging system may leave a HIPAA compliant message. The message will be considered acceptable phone contact as long as all the required information is provided.

If electronic noticing is the preferred method, and the electronic notification is sent timely.

  • If the MCO receives indication that the electronic notification was undeliverable, the MCO shall provide the required phone notice and/or send the required written notification in compliance with applicable law or regulation.

Documentation:

The authorization case record must include documentation of the following:

  • Dates and times of all attempted calls,
  • Result of the calls; and
  • The written notification to the enrollee/designee and the requesting provider or provider’s representative as required pursuant to Article 49 of the Public Health Law, 42 CFR 438, the Model Contracts, or 42 CFR 457, CHPlus Subscriber Contract/Member Handbook.
  • When electronic noticing is the preferred contact method:
    • Time
    • Date
    • Method
    • Content
    • Record of electronic transmittal
  • If electronic notice was undeliverable:
    • Dates and times of all attempted calls
    • The results of the calls; and
    • The written notification to the enrollee/designee and the requesting provider or provider’s representative as required pursuant to Article 49 of the Public Health Law, 42 CFR 438; or
    • If electronic noticing is the enrollee/designee’s preferred method of receiving written notice:
      • The time, date, method, content and record of electronic transmittal of the written notice by electronic means.

**If an enrollee does not want to be called, the MCO cannot rely on the "Do Not Call Registry". The Plan must have a written consent/documentation that enrollee does not want MCO to contact them. Such documentation should be included in the case file. Providers must be called or electronically notified regardless of receipt of a request not to be called.