Common use of Responding to Direct Requests By a Member for a Service Clause in Contracts

Responding to Direct Requests By a Member for a Service. When a member requests a health or long-term care service or item, IDT staff shall do all of the following: a. Acknowledge receipt of the request and explain to the member the process to be followed in processing the request; b. Using the RAD or other Department approved guidelines, promptly determine what the core issue is in relation to the request. Assess if the request meets a need defined in the member’s long term outcomes. c. Determine whether the request is for an item or service included in the Family Care Benefit package (if not, the MCO may authorize the service only if it complies with the requirements set forth in Article VII.A.7.); d. Promptly determine whether the IDT has the authority to authorize the requested service or whether the authorization decision must be made outside the IDT (see Section K.4., Service Authorization Decisions Made Outside the IDT, in this article); e. Consult as needed with other health care professionals who have appropriate clinical expertise in treating the member's condition or disease necessary to reach a service authorization decision. f. Issue a prompt decision as follows: i. If IDT staff are authorized to provide or arrange the service, make a prompt decision to approve or to disapprove the request based on the RAD or other Department-approved service authorization policies and procedures. The member is always a participant in the RAD or other Department-approved service authorization policies and procedures. ii. If the service authorization process requires that additional MCO employees or other professionals be involved in decision-making about a member request for service, the MCO shall assure that: a) The additional MCO employee(s) shall join with the IDT staff; b) The expanded IDT shall use the RAD or other Department- approved service authorization policies and procedures with the member; and c) The IDT shall make the final decision taking into consideration the recommendations of the MCO employees or other professionals. iii. If the service authorization process requires that the IDT seek additional information outside the team prior to authorization or approval, assure that the additional information is obtained promptly. iv. The timeframe for decision-making must be in accordance with the timeframe outlined in paragraph 9, Timeframe for Decisions, below. g. If the IDT staff determines that the service or the amount, duration or scope of the service is not necessary or appropriate and therefore approves less service than requested or declines to provide or authorize the service, the IDT staff shall do all of the following: i. Within the timeframes identified in paragraph 9 below, if the service or item requested is in the benefit package, provide the member notice of adverse benefit determination of any decision by the team to deny a request, or to authorize a service in an amount, duration, or scope that is less than requested. Failure to reach a service authorization decision within the timeframes specified in paragraph 9, Timeframe for Decisions, below constitutes a denial and therefore requires a notice of adverse benefit determination. The adverse benefit determination notice must meet the requirements of Article XI, Grievances and Appeals, page 180. ii. When appropriate, notify the rendering provider of the authorization decision. Notices to providers need not be in writing. iii. All service requests, which are denied, limited, or discontinued, shall be recorded, along with the disposition. Aggregate data on service requests that are denied, limited, or discontinued are compiled for use in quality assessment and monitoring and shall be made available to the Department upon request. iv. Although the MCO may cover alternative services (i.e., services outside the benefit package) as described in Article VII, Section A.7., an MCO is not required to provide a notice of adverse benefit determination when it denies a member’s request for alternate service. However, the MCO is required to inform the member in writing within 14 (fourteen) days when a request for an alternative service is denied. The MCO must utilize DHS’ Notification of Non Covered Benefit template (xxxxx://xxx.xxx.xxxxxxxxx.xxx/library/f-01283.htm). The IDT staff will continue to ensure that the member’s health and long- term care outcomes are supported.

Responding to Direct Requests By a Member for a Service. When a member requests a health or long-term care service or item, IDT staff shall do all of the following: a. Acknowledge receipt of the request and explain to the member the process to be followed in processing the request; b. Using the RAD or other Department approved guidelines, promptly determine what the core issue is in relation to the request. Assess if the request meets a need defined in the member’s long term outcomes. c. Determine whether the request is for an item or service included in the Family Care Benefit package (if not, the MCO may authorize the service only if it complies with the requirements set forth in Article VII.A.7.); d. Promptly determine whether the IDT has the authority to authorize the requested service or whether the authorization decision must be made outside the IDT (see Section K.4., Service Authorization Decisions Made Outside the IDT, in this article); e. Consult as needed with other health care professionals who have appropriate clinical expertise in treating the member's condition or disease necessary to reach a service authorization decision. f. Issue a prompt decision as follows: i. If IDT staff are authorized to provide or arrange the service, make a prompt decision to approve or to disapprove the request based on the RAD or other Department-approved service authorization policies and procedures. The member is always a participant in the RAD or other Department-approved service authorization policies and procedures. ii. If the service authorization process requires that additional MCO employees or other professionals be involved in decision-making about a member request for service, the MCO shall assure that: a) The additional MCO employee(s) shall join with the IDT staff; b) The expanded IDT shall use the RAD or other Department- approved service authorization policies and procedures with the member; and c) The IDT shall make the final decision taking into consideration the recommendations of the MCO employees or other professionals. iii. If the service authorization process requires that the IDT seek additional information outside the team prior to authorization or approval, assure that the additional information is obtained promptly. iv. The timeframe for decision-making must be in accordance with the timeframe outlined in paragraph 9, Timeframe for Decisions, below. g. If the IDT staff determines that the service or the amount, duration duration, or scope of the service is not necessary or appropriate and therefore approves less service than requested or declines to provide or authorize the service, the IDT staff shall do all of the following: i. Within the timeframes identified in paragraph 9 below, if the service or item requested is in the benefit package, provide the member notice of adverse benefit determination of any decision by the team to deny a request, or to authorize a service in an amount, duration, or scope that is less than requested. ii. Failure to reach a service authorization decision within the timeframes specified in paragraph 9, Timeframe for Decisions, below constitutes a denial and therefore requires a notice of adverse benefit determination. The adverse benefit determination notice must meet the requirements of Article XI, Grievances and Appeals, page 180. ii. When appropriate, notify the rendering provider of the authorization decision. Notices to providers need not be in writing. iii. All service requests, which are denied, limited, or discontinued, shall be recorded, along with the disposition. Aggregate data on service requests that are denied, limited, or discontinued are compiled for use in quality assessment and monitoring and shall be made available to the Department upon request. iv. Although the MCO may cover alternative services (i.e., services outside the benefit package) as described in Article VII, Section A.7., an MCO is not required to provide a notice of adverse benefit determination when it denies a member’s request for alternate service. However, the MCO is required to inform the member in writing within 14 (fourteen) days when a request for an alternative service is denied. The MCO must utilize DHS’ Notification of Non Covered Benefit template (xxxxx://xxx.xxx.xxxxxxxxx.xxx/library/f-01283.htm). The IDT staff will continue to ensure that the member’s health and long- term care outcomes are supported.,

Responding to Direct Requests By a Member for a Service. When a member requests a health or long-term care service or item, IDT staff shall do all of the following: a. Acknowledge receipt of the request and explain to the member the process to be followed in processing the request; b. Using the RAD or other Department approved guidelines, promptly determine what the core issue is in relation to the request. Assess if the request meets a need defined in the member’s long term outcomes. c. Determine whether the request is for an item or service included in the Family Care Benefit package (if not, the MCO may authorize the service only if it complies with the requirements set forth in Article VII.A.7.); d. Promptly determine whether the IDT has the authority to authorize the requested service or whether the authorization decision must be made outside the IDT (see Section K.4., Service Authorization Decisions Made Outside the IDT, in this article); e. Consult as needed with other health care professionals who have appropriate clinical expertise in treating the member's condition or disease necessary to reach a service authorization decision. f. Issue a prompt decision as follows: i. If IDT staff are authorized to provide or arrange the service, make a prompt decision to approve or to disapprove the request based on the RAD or other Department-approved service authorization policies and procedures. The member is always a participant in the RAD or other Department-approved service authorization policies and procedures. ii. If the service authorization process requires that additional MCO employees or other professionals be involved in decision-making about a member request for service, the MCO shall assure that: a) The additional MCO employee(s) shall join with the IDT staff; b) The expanded IDT shall use the RAD or other Department- approved service authorization policies and procedures with the member; and c) The IDT shall make the final decision taking into consideration the recommendations of the MCO employees or other professionals. iii. If the service authorization process requires that the IDT seek additional information outside the team prior to authorization or approval, assure that the additional information is obtained promptly. iv. The timeframe for decision-making must be in accordance with the timeframe outlined in paragraph 9, Timeframe for Decisions, below. g. If the IDT staff determines that the service or the amount, duration or scope of the service is not necessary or appropriate and therefore approves less service than requested or declines to provide or authorize the service, the IDT staff shall do all of the following: i. Within the timeframes identified in paragraph 9 below, if the service or item requested is in the benefit package, provide the member notice of adverse benefit determination action of any decision by the team to deny a request, or to authorize a service in an amount, duration, or scope that is less than requested. Failure to reach a service authorization decision within the timeframes specified in paragraph 9, Timeframe for Decisions, below constitutes a denial and therefore requires a notice of adverse benefit determinationaction. The adverse benefit determination notice of action must meet the requirements of Article XI, Grievances and Appeals, page 180176. ii. When appropriate, notify the rendering provider of the authorization decision. Notices to providers need not be in writing. iii. All service requests, which are denied, limited, or discontinued, shall be recorded, along with the disposition. Aggregate data on service requests that are denied, limited, or discontinued are compiled for use in quality assessment and monitoring and shall be made available to the Department upon request. iv. Although the MCO may cover alternative services (i.e., services outside the benefit package) as described in Article VII, Section A.7., an MCO is not required to provide a notice of adverse benefit determination action when it denies a member’s request for alternate service. However, the MCO is required to inform the member in writing within 14 (fourteen) days when a request for an alternative service is denied. The MCO must utilize DHS’ Notification of Non Covered Benefit template (xxxxx://xxx.xxx.xxxxxxxxx.xxx/library/f-01283.htmxxxxx://xxx.xxx.xxxxxxxxx.xxx/forms/f0/f01283.doc). The IDT staff will continue to ensure that the member’s health and long- long-term care outcomes are supported.

Responding to Direct Requests By a Member for a Service. When a member requests a health or long-term care service or item, IDT staff shall do all of the following: a. Acknowledge receipt of the request and explain to the member the process to be followed in processing the request; b. Using the RAD or other Department MCO’s DHS-approved guidelines, promptly determine what the core issue is in relation to the request. Assess if the request meets a need defined in the member’s long term outcomes.; c. Determine whether the request is for an item or service included in the Family Care Benefit package (if not, the MCO IHCP may authorize the service only if it complies with the requirements set forth in Article VII.A.7.VI.B.); d. Promptly determine whether the IDT has the authority to authorize the requested service or whether the authorization decision must be made outside the IDT (see Section K.4., Service Authorization Decisions Made Outside the IDT, in this article); e. Consult as needed with other health care professionals who have appropriate clinical expertise in treating the member's condition or disease necessary to reach a service authorization decision.; f. e. Issue a prompt decision as follows: i. If IDT staff are authorized to provide or arrange the service, make a prompt decision to approve or to disapprove the request based on the RAD or other DepartmentMCO’s DHS-approved service authorization policies and procedures. The member is always a participant in the RAD or other DepartmentMCO’s DHS-approved service authorization policies and procedures. ii. If the service authorization process requires that additional MCO IHCP employees or other professionals be involved in decision-making about a member request for service, the MCO IHCP shall assure that: a) The additional MCO IHCP employee(s) shall join with the IDT staff; b) The expanded IDT shall use the RAD or other Department- MCO’s DHS-approved service authorization policies and procedures with the member; and c) The IDT shall make the final decision taking into consideration the recommendations of the MCO IHCP employees or other professionals. iii. If the service authorization process requires that the IDT seek additional information outside the team prior to authorization or approval, assure that the additional information is obtained promptly. iv. The timeframe for decision-making must be in accordance with the timeframe outlined in paragraph 98, Timeframe for Decisions, below. g. f. If the IDT staff determines that the service or the amount, duration or scope of the service is not necessary or appropriate and therefore approves less service than requested or declines to provide or authorize the service, the IDT staff shall do all of the following: i. Within the timeframes identified in paragraph 9 8 below, if the service or item requested is in the benefit package, provide the member notice of adverse benefit determination action of any decision by the team to deny a request, or to authorize a service in an amount, duration, or scope that is less than requested. Failure to reach a service authorization decision within the timeframes specified in paragraph 98, Timeframe for Decisions, below constitutes a denial and therefore requires a notice of adverse benefit determinationaction. The adverse benefit determination notice of action must meet the requirements of Article XIX, Grievances and Appeals, page 180. ii. When appropriate, notify the rendering provider of the authorization decision. Notices to providers need not be in writing. iii. All service requests, which are denied, limited, or discontinued, shall be recorded, along with the disposition. Aggregate data on service requests that are denied, limited, or discontinued are compiled for use in quality assessment and monitoring and shall be made available to the MCO or Department upon request. iv. Although the MCO may cover alternative services (i.e., services outside the benefit package) as described in Article VII, Section A.7., an MCO is not required to provide a notice of adverse benefit determination when it denies a member’s request for alternate service. However, the MCO is required to inform the member in writing within 14 (fourteen) days when a request for an alternative service is denied. The MCO must utilize DHS’ Notification of Non Covered Benefit template (xxxxx://xxx.xxx.xxxxxxxxx.xxx/library/f-01283.htm). The IDT staff will continue to ensure that the member’s health and long- term care outcomes are supported.

Responding to Direct Requests By a Member for a Service. When a member requests a health or long-term care service or item, IDT staff shall do all of the following: a. Acknowledge receipt of the request and explain to the member the process to be followed in processing the request; b. Using the RAD or other Department approved guidelines, promptly determine what the core issue is in relation to the request. Assess if the request meets a need defined in the member’s long term outcomes. c. Determine whether the request is for an item or service included in the Family Care Benefit package (if not, the MCO may authorize the service only if it complies with the requirements set forth in Article VII.A.7.); d. Promptly determine whether the IDT has the authority to authorize the requested service or whether the authorization decision must be made outside the IDT (see Section K.4., Service Authorization Decisions Made Outside the IDT, in this article); e. Consult as needed with other health care professionals who have appropriate clinical expertise in treating the member's condition or disease necessary to reach a service authorization decision. f. Issue a prompt decision as follows: i. If IDT staff are authorized to provide or arrange the service, make a prompt decision to approve or to disapprove the request based on the RAD or other Department-approved service authorization policies and procedures. The member is always a participant in the RAD or other Department-approved service authorization policies and procedures. ii. If the service authorization process requires that additional MCO employees or other professionals be involved in decision-making about a member request for service, the MCO shall assure that: a) The additional MCO employee(s) shall join with the IDT staff; b) The expanded IDT shall use the RAD or other Department- approved service authorization policies and procedures with the member; and c) The IDT shall make the final decision taking into consideration the recommendations of the MCO employees or other professionals. iii. If the service authorization process requires that the IDT seek additional information outside the team prior to authorization or approval, assure that the additional information is obtained promptly. iv. The timeframe for decision-making must be in accordance with the timeframe outlined in paragraph 9, Timeframe for Decisions, below. g. If the IDT staff determines that the service or the amount, duration or scope of the service is not necessary or appropriate and therefore approves less service than requested or declines to provide or authorize the service, the IDT staff shall do all of the following: i. Within the timeframes identified in paragraph 9 below, if the service or item requested is in the benefit package, provide the member notice of adverse benefit determination action of any decision by the team to deny a request, or to authorize a service in an amount, duration, or scope that is less than requested. Failure to reach a service authorization decision within the timeframes specified in paragraph 9, Timeframe for Decisions, below constitutes a denial and therefore requires a notice of adverse benefit determinationaction. The adverse benefit determination notice of action must meet the requirements of Article XI, Grievances and Appeals, page 180169. ii. When appropriate, notify the rendering provider of the authorization decision. Notices to providers need not be in writing. iii. All service requests, which are denied, limited, or discontinued, shall be recorded, along with the disposition. Aggregate data on service requests that are denied, limited, or discontinued are compiled for use in quality assessment and monitoring and shall be made available to the Department upon request. iv. Although the MCO may cover alternative services (i.e., services outside the benefit package) as described in Article VII, Section A.7., an MCO is not required to provide a notice of adverse benefit determination action when it denies a member’s request for alternate service. However, the MCO is required to inform the member in writing within 14 (fourteen) days when a request for an alternative service is denied. The MCO must utilize DHS’ Notification of Non Covered Benefit template (xxxxx://xxx.xxx.xxxxxxxxx.xxx/library/f-01283.htm)template. The IDT staff will continue to ensure that the member’s health and long- long-term care outcomes are supported.