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.
