Our UM represents a combination of different disciplines, including utilization review with benefit and eligibility requirements, effective and appropriate delivery of medically necessary services, quality of care across the continuum, discharge planning, and case management.
Our Clinical Services department monitors services provided to members to identify potential areas of over and underutilization. UM decision-making is based only on appropriateness of care and service and the existence of coverage. We do not specifically reward or offer incentives to practitioners or other individuals for issuing denials of coverage or service care. Financial incentives for UM decision-makers do not encourage decisions that result in underutilization.
We have adopted the MCGTM Care Guidelines and criteria for inpatient and ambulatory care where no specific Oxford policy exists. We also develop specific policies related to covered services. Each policy describes the service and its appropriate utilization.
We employ several means to review the consistency and quality of clinical decision-making as directed through policies and adopted guidelines. The following processes are in addition to those required by regulatory agencies and NCQA:
- Inter-rater reliability tests developed in conjunction with an external consultant
- Monthly medical director consistency meetings and case discussions
- Monthly blind reviews done by all medical directors on a common set of clinical factors
We employ a process for adopting and updating clinical practice guidelines for use by network care providers and other health care professionals. Clinical practice guidelines help practitioners and members make decisions about health care in specific clinical situations. We develop guidelines for preventive screening, acute and chronic care, and appropriate drug usage based on:
- Availability of accepted national guidelines
- Ability to monitor compliance
- Projected ability to make a significant impact upon important aspects of care
Oxford may perform clinical reviews for various reasons, including but not limited to, medical necessity
determinations, member eligibility, and to validate accuracy of coding for services or procedures requested or rendered by participating or non-participating care providers and other qualified health care professionals. We consider medically necessary services for reimbursement when rendered to eligible members, as reflected in the clinical information, provided the services are not fraudulent or abusive.
Oxford may review clinical information on an entire population of, or a subset of care providers, procedures or members, at our discretion. We may review this information prospectively, concurrently and/or retrospectively. We define clinical information as the member’s clinical condition, which may include symptoms, treatments, dosage and duration of drugs, and dates for other therapies. Dates of prior imaging studies performed and other information the ordering care provider believes is useful in evaluating whether the service ordered meets current evidence-based clinical guidelines, such as prior diagnostic tests and consultation reports, should be provided.
Clinical information reviewed prospectively may be reviewed again concurrently or retrospectively to confirm the accuracy of the information available at the time of previous review. Oxford will retrospectively deny an approval only in circumstances indicated in the approval or in circumstances involving fraud, abuse or material misrepresentation.
The procedure and information required for review will depend on the circumstances of interest, as determined by Oxford.
The process of selecting services for review, requests for clinical information concerning such services, review of clinical information, and action based on clinical information complies with all relevant federal and state regulations, laws, and provisions in your contract with Oxford. We provide information on appeal rights for adverse determinations as required by law and regulation.
All adverse utilization review (UR) determinations (whether initial or on appeal) are made by a clinical peer reviewer. Appeals of adverse UR determinations will be reviewed by a different clinical peer reviewer than the clinical peer reviewer who rendered the initial adverse determination.
Initial Utilization Review Determination Time Periods
We make UR decisions by the following methods and in the following time frames:
Prior Authorization - We make UR decisions and provide notice to you and the member, by phone and in writing, within three business days of receipt of necessary information.
Concurrent review - We make UR decisions and provide notice to the member or their designee by phone and writing within one business day of receipt of necessary information
Retrospective - We will make UR decisions within 30 days of receipt of necessary information. We may reverse a preauthorized treatment, service or procedure on retrospective review whan all the following circumstances occur:
- Relevant medical information presented to us or UR agent during retrospective review is materially different from the information presented during the preauthorization review.
- The information existed at the time of the preauthorization review but was withheld or not made available.
- UnitedHealthcare or the UR agent was not aware of the existence of the information at the time of the preauthorization review.
- If we had been aware of the information, we would not have authorized the treatment, service or procedure requested.
If an initial adverse UR determination is rendered without attempting to discuss such matter with the member’s care provider or other health care professional who specifically recommended the health care service, procedure or treatment under review, such care providers and other health care professionals have the opportunity to request reconsideration of the adverse determination. Except in cases of retrospective reviews, the medical director or other health care professional conducts the review as the clinical peer reviewer and make the determination within one business day of receipt of the request.
Failure to make an initial UR determination within the time periods described is deemed to be an adverse determination eligible for appeal.
Components of an Initial Adverse Determination
If the review results in an adverse determination, the initial adverse determination letter includes the following:
- Reasons for the determination, including clinical rationale.
- Instructions on how to initiate internal appeals (standard and expedited appeals) and eligibility for external appeals.
- Clinical review criteria relied upon to make our decision is provided upon request from the member or the member’s designee.
- Any other necessary information that must be provided to, or obtained by us, to render a decision on an appeal of our determination.
Member appeals must be submitted to us or our delegate within 180 days from the receipt of the initial adverse UR determination. Standard (non-expedited) UR appeals may be filed by telephone or in writing by the member or their designee. Member appeals may be initiated in writing or by calling our Member Service department at the number on the member’s health care ID card or at 800-444-6222. However, we strongly recommend the appeal be filed in writing. Determinations concerning services that have already been provided are not eligible to be appealed on an expedited basis. In the event that only a portion of such necessary information is received, we request the missing information, in writing, within five business days of receipt of partial information. If a determination is not made within 15 days of the filing of the appeal, we provide written acknowledgment to the appealing party within 15 days of the filing of a standard appeal.
Expedited UR Appeals
An expedited UR appeal may be filed for denials of:
- Continued or extended health care services, procedures or treatment.
- Additional services for member undergoing a course of continued treatment.
- Health care services for which the care provider or other health care professional believes an immediate appeal is warranted.
We make a decision on expedited UR appeals within two business days of receipt of the information necessary to conduct such appeal. If we require more information to conduct an expedited appeal, we immediately notify the member and their health care provider by telephone or fax to identify and request the necessary information, and follow up with a written notification. The appealing party may re-appeal an expedited appeal using the standard appeal process or through the external appeal process.
We allow you to submit an expedited member appeal without a member’s written consent. All other appeals require the member’s explicit written consent to appeal after our initial UR decision is made. A general assignment will not be accepted.
If we do not make a determination within 60 calendar days of receipt of the necessary information for a standard appeal or within two business days of receipt of necessary information for an expedited appeal, we consider the initial adverse UR determination to be reversed.
The law allows the member and UnitedHealthcare to jointly agree to waive the internal UR appeal process. Typically, we do not agree to this. In those rare situations where we are willing to waive the internal UR appeal, we inform the appeal requester and/or member verbally and/or in writing. If the member agrees to waive the internal UR appeal process, we provide them with a letter within 24 hours of the Agreement with information on filing an external appeal.
Retrospective Review Appeals (New York Provider Appeals)
A retrospective adverse determination is one where the initial medical necessity review is requested or initiated after the services have been rendered. This process does not apply to services where precertification or concurrent review is required. You may request an external appeal on your own behalf, by phone or in writing, when we have made a retrospective final adverse determination on the basis that the service or treatment is not medically necessary or is considered experimental or investigational (or is an approved clinical trial) to treat the member’s life- threatening or disabling condition (as defined by the New York State Social Security Law).
All requests for such internal retrospective appeals must be made within 60 days of receipt of the initial retrospective medical necessity or experimental/investigational determination. If we require more information to conduct a standard internal appeal, we notify the member and their health care provider, in writing, within 15 days of receipt of the appeal, to identify and request necessary information.
Once we make a decision about the retrospective review appeal, we notify the member and their care provider in writing within two business days from the date we make the decision.
If the decision is adverse, and you continue to dispute our decision, you may be eligible for an external appeal through the New York external appeal process. Hospitals and other facilities may have alternate dispute mechanisms in place for review of these issues instead of external appeal. Please check your contract for more information.
Internal retrospective appeals submitted after the 60-day time frame is not handled through this process. If your appeal is still submitted within the contractual deadlines for an appeal, we automatically handle it through the contractual appeal process discussed in the next section.
Medical Necessity Internal Appeals Process for Care Providers Under Your Contract
If we make a decision that a requested service is not medically necessary, you may dispute our determination. Mail a written request, with supporting clinical documentation showing why we should reverse the denial of services, to:
Oxford Clinical Appeals Department
P.O. Box 29139
Hot Springs, AR 71903
The Clinical Appeals department makes a reasonable effort to render a decision within 60 calendar days of receiving the appeal and supporting documentation. If the contractual appeal decision is adverse, and you continue to dispute the decision, the dispute may be eligible for arbitration under your contract.
Note: There is a separate appeal process for internal member appeals and retrospective provider appeals under New York law. These processes do not apply to contractual appeals.
Appeals not submitted within the contractual time frames are denied.
Utilization Review Appeals
UR occurs whenever judgments pertaining to medical necessity and the provision of services or treatments are rendered. The UR appeals process should be used after you receive an initial adverse UR determination, and you do not agree with our decision. All appeals are subject to a review by us to evaluate the medical necessity of the services. You may use this process to appeal adverse determinations relating to all UR determinations, regardless of whether the services requested by you or your authorized representative have not yet been rendered (pre- service), are currently being rendered (concurrent) or have already been rendered (post-service).
Note: This UR appeals process should not be used for appeals relating to benefit, network or administrative issues.
UR appeals must be initiated within 180 days from receipt of an adverse determination (i.e., receipt of the determination notice). A decision may be rendered within the standard time frames or may be expedited as described in this section.
While a UR appeal may be filed by telephone or in writing, we strongly recommend you file your appeal in writing. The written request will give us a clear understanding of the issues being appealed. In addition to your request for an appeal, you or your authorized representative must send documentation/information already requested by us (if not previously submitted) and additional written comments and documentation/information you would like to submit in support of the appeal. At the time of our review, we will review all available comments, documentation and information.
Unless we already issued a written determination, we use our best efforts to provide written acknowledgement of the receipt of your appeal within five business days but not later than 15 calendar days. Our decision to either uphold or reverse the adverse determination is made and communicated to you as follows:
- Request for service (pre-service): Within 30 calendar days of our receipt of the appeal. However, if additional information is requested, a determination is made within three business days of our receipt of the information, or the expiration of the period allowed to provide the information (i.e., 45 days).
- Concurrent services for a member in an ongoing course of treatment (concurrent): Within 30 calendar days of our receipt of the appeal. In this instance, treatment is continued without liability while your appeal is being reviewed. However, if additional information is requested, a determination is made within one business day of our receipt of the information, or the expiration of the period allowed to provide the information (i.e., 45 days).
- Coverage for services rendered (post-service): Within 60 calendar days of our receipt of the appeal. However, if additional information is requested, a determination is made within 15 days of our receipt of the information, or the expiration of the period allowed to provide the information (i.e., 45 days).
If we do not follow the process outlined in this section, you will have been deemed to have exhausted the internal appeals process. You may then file a request for an external review (see below), regardless of whether we can assert substantial compliance or de minimis error.
This will be our final adverse determination. If you are not satisfied with our decision, you have the option of filing an External Appeal (explained in the following section, “External Appeals”).
You can expedite your UR appeal when:
- You receive an adverse determination involving continued or extended health care services, procedures or treatments or additional services while you are undergoing a course of continued treatment (concurrent) prescribed by a health care provider; or
- The time frames of the non-expedited UR appeal process would seriously jeopardize your life, health or ability to regain maximum function; or
- In the opinion of a care provider with knowledge of the health condition, the time frames of the non-expedited UR appeal process would cause you severe pain that cannot be managed without care or treatment requested; or
- Your care provider believes an immediate appeal is necessary because the time frames of the non-expedited UR appeal process would significantly increase the risk to your health; or
- For a substance use disorder, a co-occurring mental disorder or a mental disorder requiring inpatient services, partial hospitalization, residential treatment or intensive outpatient services necessary to keep a covered person from requiring an inpatient setting.
You have two available options for expedited reviews. These options are not available for health care services that have already been rendered (post-service).
1. Internal Expedited UR Appeal: This process includes procedures to facilitate a timely resolution of the appeal including, but not limited to, the sharing of information between your care provider and us by telephone or fax.
We provide reasonable access to our clinical peer reviewer within one business day of receiving notice of an expedited UR appeal.
A decision is rendered and communicated for an internal expedited UR appeal within the following time frames:
- 24 hours from our receipt of the appeal when the service being appealed is for substance use disorder or co- occurring mental disorder, and inpatient services, partial hospitalization, residential treatment or those intensive outpatient services needed to keep the member from requiring an inpatient setting in connection with a mental disorder.
- 72 hours from our receipt of the appeal for all other types of services.
If you are not satisfied with the outcome of the expedited UR appeal, you may further appeal through the external appeal process. If we do not make a determination within 72 hours of receipt of the necessary information, the adverse determination is reversed.
The notice of an appeal determination includes reasons for the determination. If the adverse determination is upheld on appeal, the notice will include the specific reason(s) and clinical rationale used to render the determination, a reference to the specific health benefit plan provisions on which the decision is based, a statement you may receive from us (upon request and free of charge) reasonable access to and copies of all relevant documents. We also include a notice of your right to initiate an external appeal. A description of each process and associated time frames is included.
If we do not follow the process outlined in this section, you will have been deemed to have exhausted the internal appeals process. You may then file a request for an external review (see the following bullet), regardless of whether we can assert substantial compliance or de minimis error.
2. External Expedited Appeal: You have the option to seek review by an independent review organization in emergency or life-threatening circumstances. You may make a request to the Commissioner of Insurance for an expedited external appeal without first completing the internal appeals process if:
- The time frame for completion of an expedited internal appeal may cause or exacerbate an emergency or life- threatening situation; or
- For a substance use disorder, a co-occurring mental disorder or a mental disorder requiring inpatient services, partial hospitalization, residential treatment or intensive outpatient services necessary to keep a covered person from requiring an inpatient setting; and
- The member or you, acting on their behalf with their consent, filed a request for expedited internal review.
If you choose this option, you must submit the appeal by contacting:
Connecticut Insurance Department PO Box 816
Hartford, CT 06142-0816
For more information on how to file an expedited external appeal, refer to External UR Appeals below.
The contents of a FAD vary based on the state in which the member’s certificate of coverage was issued. Each notice of FAD is in writing, dated and includes the following:
- Information sufficient to identify the benefit request or claim involved, including the date of service, the health care professional and the claim amount, if known.
- The specific reason(s) for the adverse determination, including, upon request, a listing of relevant clinical review criteria including professional criteria and medical or scientific evidence used to reach the denial and a description of Oxford’s standard, internal rule, guideline, protocol or other criterion, if applicable, used in reaching the denial.
- Reference to the specific health benefit plan provisions we used to reach the denial.
- A description of other material or information necessary for the covered person to perfect the benefit request or claim, including an explanation of why the material or information is necessary to perfect the request or claim.
- A description of Oxford’s internal appeals process, which includes:
i. Oxford’s expedited review procedures,
ii. Limits applicable to such process or procedures,
iii. Contact information for the organizational unit designated to coordinate the review on behalf of the health carrier, and
iv. A statement the member or their authorized representative is entitled, following requirements of Oxford’s internal grievance process, to receive from Oxford, free of charge upon request, reasonable access to and copies of all documents, records, communications and other information and evidence regarding the request.
If the adverse determination is based on:
1. An internal rule, guideline, protocol or other similar criteria:
i. The specific rule, guideline, protocol or other similar criteria; or
ii. A statement that:
- A specific rule, guideline, protocol or other similar criteria was relied upon to make the adverse determination and a copy of such rule, guideline, protocol or other similar criteria will be provided to the covered person free of charge upon request;
- Provides instructions for requesting a copy; and
- The links to such rule, guideline, protocol or other similar criteria on Oxford’s website.
2. Medical necessity or an experimental/investigational treatment:
i. A written statement of the scientific or clinical rationale used to render the decision that applies the terms of the benefit plan to the member’s medical circumstance;
ii. Notification of the member’s right to receive, free of charge upon request, reasonable access to and copies of all documents, records, communications and other information and evidence not previously provided regarding the adverse determination under review;
3. A statement explaining the right of the member to contact the Office of the Healthcare Advocate at any time for assistance or, upon completion of Oxford’s internal grievance process, to file a civil suit in a court of competent jurisdiction. Such statement shall include:
i. The contact information for said offices; and
ii. A statement if the member or their authorized representative chose to file a grievance that:
- Appeals are sometimes successful;
- The member may benefit from free assistance from the Office of the Healthcare Advocate, which may assist them with filing a grievance pursuant to 42 USC 300gg–93, as amended from time to time;
- The member is entitled and encouraged to submit supporting documentation for Oxford’s consideration during the review of an adverse determination, including narratives from the member or from their authorized representative and letters and treatment notes from the member’s health care professional; and
- The member has the right to ask their health care professional for such letters or treatment notes.
4. A health carrier may offer a member’s health care professional the opportunity to confer with a clinical peer as long as a grievance has not already been filed prior to the conference. This conference between the physician and the health care professional peer will not be considered a grievance of the initial adverse determination.
- Information sufficient to identify the claim involved, including date of service, health care provider, claim amount (if applicable) and a statement describing the availability, upon request, of the diagnosis code and its corresponding meaning and the treatment code and its corresponding meaning. Any request for such diagnosis and treatment information following an initial adverse benefit determination shall be responded to as soon as practicable, and the request itself shall not be considered a request for a stage 1, stage 2 or stage 3 appeal;
- The reason(s) for the adverse benefit determination, including denial code and corresponding meaning, as well as a description of the standard used by Oxford in the denial;
- Any new or additional rationale, which was relied upon, considered or used, or generated by Oxford, in connection with the adverse benefit determination; and
- Information regarding the availability and contact information for the consumer assistance program at the Department of Banking and Insurance, which assists covered persons with claims, internal appeals and external appeals, which shall include the address and telephone number at N.J.A.C. 11:24-8.7(b).
- The specific reason for denial, reduction or termination of services.
- The specific health service that was denied, including the name of the facility/care provider and developer/ manufacturer of service, as available.
- A statement that the member may be eligible for an appeal, and a description of appeal procedures including a description of the urgent appeal process if the claim involves urgent care.
- A clear statement, in bold, that the member has 45 days from the FAD to request an external appeal, and that choosing the second level internal appeal may exhaust the time limits required for filing an external appeal.
- A description of the external appeals process.
If Oxford fails to adhere to these requirements for rendering decisions, the following rules apply to members enrolled in Connecticut and New Jersey products.
Connecticut: The member is deemed to have exhausted Oxford’s internal appeals process and may file an external review, even if Oxford could prove substantial compliance or minor (de minimis) error.
New Jersey: Members are not obligated to complete the internal review process and may proceed directly to the external review process under the following circumstances:
- We fail to comply with any deadlines for completion of the internal appeals process without demonstrating good cause or because of matters beyond our control while in the context of an ongoing, good faith exchange of information between parties and it is not a pattern or practice of non-complianc
- We for any reason expressly waive our rights to an internal review of any appeal; or
- The member and/or their care provider applied for expedited external review at the same time as applying for an expedited internal review.
In such a case where Oxford asserts good cause for not meeting the deadlines of the appeals process, members or their designee and/or their care provider may request a written explanation of the violation. Oxford must provide the explanation within 10 days of the request and must include a specific description of the basis for which we determine the violation should not cause the internal appeals process to be exhausted. If an external reviewer or court agrees with Oxford and rejects the request for immediate review, the member has the opportunity to resubmit their appeal.
The member has a right to an external appeal of a FAD.
A FAD is a first-level appeal denial of an otherwise covered service where the basis for the decision is either a lack of medical necessity, appropriateness, health care setting, level of care or effectiveness or the experimental/ investigational exclusion.
The care provider’s certification must include a statement of the evidence relied upon by the care provider in certifying their recommendation, and an external appeal must be submitted within 45 days upon receipt of the FAD, whether a second-level appeal is requested or not. If a member chooses to request a second-level internal appeal, the time may expire for the member to request an external appeal.
An external appeal may also be filed:
- When the member had coverage of a health care service denied on the basis that such service is experimental or investigational, and
- The denial has been upheld on appeal or both UnitedHealthcare and the member have jointly agreed to waive any internal appeal, and
- The member’s attending care provider certified that the member has a life-threatening or disabling condition or disease:
- For which standard health services or procedures have been ineffective or would be medically inappropriate or
- For which there does not exist a more beneficial standard health service or procedure covered by their health care plan or
- For which there exists a clinical trial, and
- The member’s attending care provider, who must be a licensed, board-certified or board-eligible care provider qualified to practice in the area of practice appropriate to treat the member’s life-threatening, or disabling condition or disease, must have recommended either:
- A health service or procedure (including a pharmaceutical product within the meaning of PHL 4900(5)(b)(B)), that based on two documents from the available medical and scientific evidence, is likely to be more beneficial to the member than any covered standard health service or procedure; or
- A clinical trial for which the member is eligible. Any care provider certification provided under this section shall include a statement of the evidence relied upon by the care provider in certifying their recommendation, and
- The specific health service or procedure recommended by the attending care provider that would otherwise be covered under the policy except for UnitedHealthcare’s determination that the health service or procedure is experimental or investigational. The member is not required to exhaust the second level of internal appeal to be eligible for an external appeal.
External Appeal Process
If the Clinical Appeals department upholds all or part of such an adverse determination, the member or their designee has the right to request an external appeal. An external appeal may be filed when:
- The member had coverage of a health care service denied on appeal, in whole or in part, on grounds that such health care service is not medically necessary but otherwise would have been a covered benefit, and
- We made a final adverse determination regarding the requested service, or
- UnitedHealthcare and the member both agreed to waive any internal appeal.
All external appeal requests may be sent to the following: New York State Insurance Department
P.O. Box 7209
Albany, NY 12224-0209