Utilization Management FAQ's for Providers
Q: If a provider sends in a case marked as Urgent or expedited, what is the turnaround time of the case?
A: If the case is deemed to be expedited in nature by the plan, the case will be resolved within 48 hours. This is the requirement of Ohio Senate Bill 129 and our 3 way contract: 22.214.171.124.2. "For expedited service authorization decisions, where the Provider indicates and the ICDS Plan determines that following the standard timeframe in Section 126.96.36.199.1 above could seriously jeopardize the Beneficiary's life or health or ability to attain, maintain, or regain maximum function, the ICDS Plan must make a decision and provide notice as expeditiously as the Beneficiary's health condition requires and no later than seventy-two (72) hours after receipt of the request for service, and effective January 1, 2018 no later than forty-eight (48) hours after receipt of the request for service.")
The provider and member will be notified of the decision.
Q: The provider sent in a non-urgent request for inpatient authorization. What is the turnaround timeframe for this decision to be rendered?
A: The plan understands the urgency related to providers having determinations for these requests. To that end, the provider should have a decision as soon as possible, but within 72 hours from receipt of the request.
Q: If a provider sends in a case and does not designate it expedited in nature, what is the turnaround time of the case?
A: The UM staff will determine if the case needs to be classified as expedited based on CMS guidance. If it is not considered expedited, and is not inpatient, the case will be resolved within 10 days.
Q: Are there any actions necessary for providers to comply with service request processing?
A: Yes. All decisions related to medical necessity are made using clinical information received from the provider. It is very important that all clinical information needed to make the decision be sent in with the case.
Q: The provider received fax or call of the intent to deny a service request. Can the provider have a peer to peer discussion?
A: Yes. All decisions related to expedited requests must be made within 48 hours. This includes clinical review and peer to peer, if a peer to peer is requested. The plan will make accommodations for peer to peer discussion within the CMS decision timeframes. Decisions cannot be changed once they have been completed in our systems. Peer to peer can occur after the decision is completed, but will have no bearing on the decision. The provider must provide necessary clinical information in order for the plan to make a timely decision. For adverse decisions, our members receive information related to their appeal rights.
Q: What is considered an expedited service?
A: Chapter 13 of the Medicare Managed Care Manual covers the definition. (Section 50) Additionally, the plan will review the request and if it does not meet CMS criteria can be downgraded to a standard request.