Common use of External Medical Review Clause in Contracts

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 cost of each review using an ODM-developed fee schedule. The MCO must ensure that the external medical review process does not interfere with the provider's right to request a peer-to-peer review, a member's right to request an appeal or state hearing, or the timeliness of appeal and/or state hearing resolutions. The MCO must include the following information to providers for decisions subject to external medical review: Information on how the provider may appeal the MCO’s decision, including timelines for the MCO to issue its appeal decision; Notification of the provider's right to request an external medical review following the MCO’s appeal decision or claims dispute resolution; Information about the provider’s ability to request external medical review within 30 calendar days after the provider's receipt of the MCO's appeal decision or claim dispute resolution and how to do so; and Notification that the external medical review is available at no cost to the provider. The MCO must transmit all information relevant to the external medical review request to the ODM-identified external medical review entity within five business days for standard requests and one business day for expedited requests of when the external medical review entity requests information related to the provider's request for an external medical review, unless the MCO decides to reverse its decision as specified in this Agreement. Relevant information includes the provider's request for authorization; request for external medical review; and all medical records, other documents and records; and additional evidence considered, relied upon, or generated by the MCO in connection with the medical necessity determination. The MCO may review the relevant information submitted by the provider with an external medical review request prior to transmitting the MCO information to the entity identified by ODM to perform the external medical review and decide to reverse the original coverage decision in part or in whole. If the MCO decides to reverse its original decision, in part or in whole, based on the review of relevant information submitted with an external medical review request, the MCO must issue a written decision to the provider within 72 hours and notify the external medical review entity. If the MCO decides to reverse its decision in part, the part that is unfavorable to the provider can move forward to external medical review. If the decision from the external medical review entity reverses the MCO's coverage decision in part or in whole, the external medical review decision is final and binding on the MCO. The MCO must comply with the written decision from the entity identified by ODM to perform external medical reviews. For reversed service authorization decisions, the MCO must authorize the services promptly and as expeditiously as the member's health condition requires, but no later than 72 hours from when the MCO receives the external medical review decision. For reversed decisions associated solely with provider payment (i.e., the service was already provided to the member), the MCO must pay for the disputed services within the timeframes established for claims payment in Appendix L, Payment and Financial Performance. The MCO must develop and use a system to capture and track the status and resolution of all external medical reviews, including external medical review volume and trends. The MCO must provide external medical review information to ODM upon request. The MCO must periodically evaluate the effectiveness of the external medical review process and identify opportunities to improve the provider experience. The MCO must use information collected from the external medical review process to improve service authorization decision-making.

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 cost of each review using an ODM-developed fee schedule. The MCO must ensure that the external medical review process does not interfere with the provider's right to request a peer-to-peer review, a member's right to request an appeal or state hearing, or the timeliness of appeal and/or state hearing resolutions. The MCO must include the following information to providers for decisions subject to external medical review: Information on how the provider may appeal the MCO’s decisionprocess, including timelines for the MCO to issue its appeal decision; Notification of the provider's right to request an external medical review following the MCO’s appeal decision or claims dispute resolution; Information about the provider’s ability to request external medical review within 30 calendar days after the provider's receipt of the MCO's appeal decision or claim dispute resolution and how to do so; and Notification that the external medical review is available at no cost to the provider. The MCO must transmit all information relevant to the external medical review request to the ODM-identified external medical review entity within five business days for standard requests and one business day for expedited requests of when the external medical review entity requests information related to the provider's request for an external medical review, unless the MCO decides to reverse its decision as specified in this Agreement. Relevant information includes the provider's request for authorization; request for external medical review; and all medical records, other documents and records; and additional evidence considered, relied upon, or generated by the MCO in connection with the medical necessity determination. The MCO may review the relevant information submitted by the provider with an external medical review request prior to transmitting the MCO information to the entity identified by ODM to perform the external medical review and decide to reverse the original coverage decision in part or in whole. If the MCO decides to reverse its original decision, in part or in whole, based on the review of relevant information submitted with an external medical review request, the MCO must issue a written decision to the provider within 72 hours and notify the external medical review entity. If the MCO decides to reverse its decision in part, the part that is unfavorable to the provider can move forward to external medical review. If the decision from the external medical review entity reverses the MCO's coverage decision in part or in whole, the external medical review decision is final and binding on the MCO. The MCO must comply with the written decision from the entity identified by ODM to perform external medical reviews. For reversed service authorization decisions, the MCO must authorize the services promptly and as expeditiously as the member's health condition requires, but no later than 72 hours from when the MCO receives the external medical review decision. For reversed decisions associated solely with provider payment (i.e., the service was already provided to the member), the MCO must pay for the disputed services within the timeframes established for claims payment in Appendix L, Payment and Financial Performance. The MCO must develop and use a system to capture and track the status and resolution of all external medical reviews, including external medical review volume and trends. The MCO must provide external medical review information to ODM upon request. The MCO must periodically evaluate the effectiveness of the external medical review process and identify opportunities to improve the provider experience. The MCO must use information collected from the external medical review process to improve service authorization decision-making.