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Independent External Review of Health Care Decisions in Vermont Department of Banking, Insurance, Securities and Health Care Administration.

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Presentation on theme: "Independent External Review of Health Care Decisions in Vermont Department of Banking, Insurance, Securities and Health Care Administration."— Presentation transcript:

1 Independent External Review of Health Care Decisions in Vermont Department of Banking, Insurance, Securities and Health Care Administration

2 Legal Basis for independent external review of health care decisions in Vermont 8 V.S.A. §4089f Regulation H-99-1 Division of Health Care Administration

3 Features of independent external review of health care decisions in Vermont: insured has the opportunity to obtain external review of insurers decision by impartial medical expert (Division of Health Care Administration contracts with independent review organizations) all final denial letters from insurers to include notice of possible right to appeal to Division of Health Care Administration

4 records of and materials prepared for reviews are exempt from public disclosure under 1 V.S.A. § 316 cost to insured: $25.00 (may be waived for financial hardship); insurer pays other costs of review representation not necessary, although insured may be represented if desired Features...

5 relatively quick decision insurer bound by decision if denial overturned insured may pursue other remedies Features...

6 Generally applies to health benefit plans, whether: managed care HMO indemnity PPO

7 This process not available for: decisions relating to mental health and substance abuse treatment decisions (see 8 V.S.A. §4089a and Regulation 95-2, Department of Banking, Insurance, Securities and Health Care Administration decisions relating to health care services covered under a Medicaid program (existing fair hearing process)

8 decisions relating to health care services covered under a Medicare program (existing Medicare appeals process) decisions relating to services provided by the Vermont Department of Corrections (existing Corrections appeals process)

9 An appealable decision under H-99-1 is a decision by a health insurer to deny, reduce or terminate health care coverage or to deny payment where: the health care service would cost the insurer at least $100.00; the insured has exhausted all internal appeal rights (see § (D) of Rule 10 for managed care plans, § 4 and § 5 of H-99-1 for health plans not subject to Rule 10)

10 the decision is based on one of four criteria: (1) medical necessity; (2) limitation on selection of a health care provider inconsistent with contract or law; An appealable decision under H-99-1 is a decision by a health insurer to deny, reduce or terminate health care coverage or to deny payment where:

11 (3) experimental/investigational/ off-label; or (4) medically based decision that a condition is preexisting.

12 Grounds for review: 1.The health care service is a covered benefit that the health insurer has determined to be not medically necessary.

13 Medically necessary care under H-99-1: Medically-necessary care means health care services including diagnostic testing, preventive services and aftercare appropriate, in terms of type, amount, frequency, level, setting, and duration to the members diagnosis or condition. Medically-necessary care must be

14 consistent with generally accepted practice parameters as recognized by health care providers in the same or similar general specialty as typically treat or manage the diagnosis or condition, and

15 1.help restore or maintain the members health; or 2.prevent deterioration of or palliate the members condition; or 3.prevent the reasonably likely onset of a health problem or detect an incipient problem.

16 2.A limitation is placed on the selection of a health care provider that is claimed by the insured to be inconsistent with limits imposed by the health benefit plan and any applicable laws and regulations. Grounds for review:

17 Limitation on selection of an out-of- network provider may be inconsistent with the Rule 10 requirement: A managed care plan shall ensure that members may obtain a referral to a health care provider outside of the managed care plans network when the managed care plan does not have a health care provider with appropriate training and experience within its

18 network who can meet the particular health care needs of the member, subject to the utilization review procedures used by the plan in accordance with Section (C) of this rule.

19 Grounds for review: 3.The health care treatment has been determined to be experimental or investigational or an off-label use of a drug.

20 Experimental or investigational services under H-99-1: Experimental or investigational services means health care items or services that are either not generally accepted by informed health care providers in the United States as effective in treating the condition, illness or diagnosis for which their

21 use is proposed, or are not proven by medical or scientific evidence to be effective in treating the condition, illness or diagnosis for which their use is proposed.

22 Off-label use of a drug under H-99-1: Off-label use of a drug means use of a drug for other than the particular condition for which approval was given by the F.D.A.

23 Grounds for review: 4.The health care service involves a medically-based decision that a condition is preexisting.

24 Other threshold requirements: individual is or was an insured of the health insurer; application made within 90 days from receipt of the written determination of the final level of insurers internal appeals process (oral request timely if confirmed in writing within 10 days);

25 the service that is the subject of the appeal reasonably appears to be a covered service under the benefits provided by contract to the insured

26 Application procedure: Individual (or representative) contacts Division of Health Care Administration for information, application and assistance with application if needed (24 hour/7 day availability for emergencies) Applicant returns completed application, copy of final denial letter and filing fee ($25.00) or request for waiver of fee due to financial hardship to Division of Health Care Administration

27 application is reviewed by Division of Health Care Administration to determine if complete, required release and designation of representative (if applicable) signed application, denial letter, contract and any additional information from insurer regarding contractual issues reviewed to determine if request meets appealable decision criteria

28 Time frames: Requests for routine review: Division must accept request or request additional information within 5 business days of receipt. If accepted, Division notifies parties of their opportunity to submit information and supporting documentation for consideration by independent review organization (within 10 days of receipt of notice).

29 Requests for routine review: Division exchanges parties submissions; they may file responsive information within 3 days. All submissions by parties sent by Division to independent review organization. If requested at time of application, insured and provider may have telephone conference with reviewer and clinical representative of insurer to review and discuss clinical evidence in appeal.

30 Requests for routine review: Independent review organization submits decision based on objective clinical evidence to Division as soon as possible consistent with the medical exigencies of the case but in not more than 30 days. Division reviews to ensure decision does not change the terms of coverage under the contract and issues to parties.

31 Time frames: Requests for expedited review: Division determines appealability immediately and notifies parties of opportunity to submit information and documentation. Parties have 48 hours to submit information and documentation; exchange and response and telephone conference conducted expeditiously.

32 Requests for expedited review: Independent review organization submits decision based on objective clinical evidence to Division as soon as possible consistent with the medical exigencies of the case but in not more than 5 days. Division reviews to ensure decision does not change the terms of coverage under the contract and issues to parties

33 Information and Documentation Submitted by the Parties: Documentation to be submitted by the health insurer: All information in its possession or control relevant to the appeal, including the review criteria used in making the decision being appealed from, copies of any applicable policies or procedures, and copies of all medical records considered by the insurer in making its initial decision and its decisions pursuant to the appeal process.

34 Documentation to be submitted by the insured: All information that the insured would like to have considered by the independent review organization, which may include at the insureds discretion written statements by either the insured and/or his or her health care providers, or both, relating to the subject of the appeal.

35 Nature of the Independent Review Organizations Decision: The review organizations final decision shall be based on objective clinical evidence, and shall consider any applicable generally-accepted practice guidelines developed by the federal government, national or professional medical societies, boards and associations, and clinical protocols or practice guidelines developed by the health insurer (although the review organization is not bound by the insurers clinical protocols or practice guidelines).

36 Nature of the Independent Review Organizations Decision: Determinations have no precedential value as to any other appeal filed with the Division. The Division may share the results of appeals related to experimental/ investigational treatments or off-label uses of drugs with independent review organizations considering subsequent appeals for informational purposes, but they are not binding.

37 Process For Reviewing Mental Health Care And Substance Abuse Treatment Health Care Decisions In Vermont: Independent Panel of Mental Health Care Providers Panel reviews decisions of mental health utilization review agents re: mental health care and substance abuse treatment. Legal basis: 8 V.S.A. § 4089a Regulation 95-2

38 Features of Independent Panel Review that Differ from External Review: Insured has opportunity to obtain external review of review agents medical necessity decision by impartial panel of Vermont mental health and substance abuse care providers Panel members include: psychiatrist, psychologist, mental health social worker, psychiatric nurse, mental health counselor and drug and alcohol counselor Review agent must inform insured of right to panel appeal if first level appeal is denied No application fee No threshold cost of service requirement Time frames differ slightly Process includes hearing before Panel


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