Informal Reconsideration. An Informal Reconsideration is the Member Provider’s telephone request to speak to Our Medical Director or a peer reviewer on the Member’s behalf about a Utilization Management decision that We have made. An Informal Reconsideration is typically based on submission of additional information or a peer-to-peer discussion. An Informal Reconsideration is available only for initial determinations that are requested within ten (10) days of the denial or Concurrent Review determinations. We will conduct an Informal Reconsideration within one (1) working day of the receipt of the request.
Informal Reconsideration. A telephone request by a Provider for additional review of a utilization management determination. Informal reconsideration is available only for initial or Concurrent Review determinations that are requested within ten (10) days of denial. Inpatient – A Member who is admitted to a Hospital as a registered bed patient for whom a Bed, Board and General Nursing Service charge is made. An Inpatient’s medical symptoms or condition must require continuous twenty- four (24) hour a day Physician and nursing intervention. If the services can be safely provided to the Member as an Outpatient, the Member does not meet the criteria for an Inpatient. Investigational – A medical treatment, procedure, drug, device, or biological product is Investigational if the effectiveness has not been clearly tested and it has not been incorporated into standard medical practice. Any determination We make that a medical treatment, procedure, drug, device, or biological product is Investigational will be based on a consideration of the following:
Informal Reconsideration a) If the MCO submits a timely response to the notice of sanction, the Department shall: • Conduct an informal reconsideration that includes a review of the evidence by a Department official who did not participate in the original recommendation; • Give the MCO a concise written decision setting forth the factual and legal basis for the decision; and • Forward the decision to CMS.
b) The Department decision described by Article XVI.E.2.g.iv.
a). becomes CMS's decision unless CMS reverses or modifies the decision within 15 days from the date of receipt by CMS.
c) If CMS reverses or modifies the Department's decision, the Department shall send the MCO a copy of CMS's decision.
Informal Reconsideration. Your request: You may obtain Informal Reconsideration of your denied request for a service if: Claim for a covered service already provided but not paid for: You may not obtain Informal Reconsideration of your denied request for the payment of a covered service. Instead, you may start the review process by seeking Formal Appeal. Our acknowledgement: UDC has 5 business days after UDC receives your request for Informal Reconsideration (“the receipt date”) to send you and your treating provider a notice that UDC got your request. Our decision: UDC has 30 days after the receipt date to decide whether UDC should change the decision and authorize your requested service. Within that same 30 days, UDC must send you and your treating provider UDC’s written decision. The written decision must explain the reasons for the decision and tell you the documents on which UDC based the decision. If UDC denies your request: You have 60 days to appeal to Level 2. If UDC grants your request: The decision will authorize the service and the appeal is over. If UDC refers your case to Level 3: UDC may decide to skip Level 1 and Level 2 and send your case straight to an independent reviewer at Level 3.
