External Medical Review. The MCO must offer an external medical review to a provider who is unsatisfied with the MCO's decision to deny, limit, reduce, suspend, or terminate a covered service (i.e., those specified in Appendix B, Coverage and Services) for lack of medical necessity. Denials for lack of medical necessity include but are not limited to: Denials, limitations, reductions, suspensions, or terminations that required clinical documentation or medical record review in making the decision to deny (includes pre-service, concurrent, and retrospective reviews); Denials, limitations, reductions, suspensions, or terminations that involved clinical judgement or medical decision-making (i.e., request was referred to a licensed practitioner for review); and Denials, limitations, reductions, suspensions, or terminations based on not meeting a clinical standard or medical necessity requirement (e.g., InterQual®, MCG®, ASAM, or OAC rule 5160-1-01, including EPSDT criteria). Decisions subject to external medical review include an adverse benefit determination in response to a service authorization request or claim payment denial due to lack of medical necessity. Service authorization requests and claim payments that are denied for reasons other than lack of medical necessity and for which no clinical review was completed by the MCO are not subject to external medical review. The MCO must require the provider to first appeal the decision to deny, limit, reduce, suspend, or terminate a covered service for lack of medical necessity using the MCO’s internal provider appeals process as specified in ORC 5160.34(B)(12) or provider claim dispute resolution process before the provider requests external medical review. If after a provider requests an external medical review the MCO and provider disagree that an MCO’s decision is subject to an external medical review, ODM or its designee will determine if an external medical review is available for the provider in accordance with this Agreement. The MCO must allow a provider to request an external medical review if the MCO does not issue its response to the provider’s internal appeal of the MCO’s decision to deny, limit, reduce, suspend, or terminate a covered service for lack of medical necessity within the required timeframes specified in ORC 5160.34(B)(12) for services authorizations or within 30 business days for provider claim disputes. The MCO must use the entity identified by ODM to perform the external medical review and must pay for the...
External Medical Review i. The MCO must offer an external medical review to a provider who is unsatisfied with the MCO's decision to deny, limit, reduce, suspend, or terminate a covered service (i.e., those specified in Appendix B, Coverage and Services) for lack of medical necessity. Services that are denied for reasons other than lack of medical necessity (e.g., the service is not covered by Medicaid) are not subject to external medical review.
External Medical Review. The review process conducted by an ODM-identified, independent, External Medical Review entity that is initiated by a Provider that disagrees with the MCO's decision to deny, limit, reduce, suspend, or terminate a covered service for lack of Medical Necessity.
External Medical Review. Provider shall utilize Health Plan’s External Medical Review if and when Provider is dissatisfied with Health Plan decisions to deny, limit, reduce, suspend, or terminate a Covered Service for lack of Medical Necessity. Covered Services denied for reasons other than lack of Medical Necessity are not subject to External Medical Review. (SC App. A.§6.g.i)
External Medical Review i. The OhioRISE Plan must offer an external medical review to a provider who is unsatisfied with the OhioRISE Plan's decision to deny, limit, reduce, suspend, or terminate a covered service (i.e., those specified in Appendix B, Coverage and Services) for lack of medical necessity. Services that are denied for reasons other than lack of medical necessity (e.g., the service is not covered by Medicaid) are not subject to external medical review.
