Non-certification appeals process

Appealing non-certification decisions for mental health/substance abuse inpatient or partial hospitalization care

Initial determination
When a clinical case manager is concerned that appropriate medical necessity criteria have not been met for mental health or substance abuse inpatient or partial hospitalization care, the clinical case manager will contact a physician advisor, who is a board-certified psychiatrist, to review the case for appropriateness of care.

1. The physician advisor, in accordance with the Priority Health Behavioral Health Department's Standards and Criteria for Utilization Management, will review the patient’s clinical information and/or speak directly to the attending physician. NOTE: Physician advisors are not required to attempt direct contact with the attending physician more than 3 times within 24 hours.
2. Within 24 hours of the time the physician advisor receives the request to review care, he/she will complete his/her review and give an initial determination about certification or non-certification of the requested level of care. NOTE: In certain cases, Priority Health may extend the determination decision by 48 hours to request additional clinical information from the practitioner/facility.
3. The clinical case manager will provide verbal and written notification of the physician advisor's decision to the facility and to the member (when applicable) within 24 hours of the request. A copy of the criteria on which the decision was based is available upon request.
   
   • When further days are certified, the clinical case manager will establish a concurrent review date with the facility.
   • When the decision is for non-certification, the notification letter will include:
   • The principal reason for the non-certification opinion
   • The availability of a physician reviewer to discuss the decision
   • The right and mechanism for initiating a medical necessity post-service reconsideration
   Practitioners can obtain this information by contacting the Behavioral Health Department.
   
4. If further days are non-certified based on the lack of medical necessity criteria, the clinical case manager will request that that facility contact Priority Health:
   • If a member's presentation significantly changes
   • With discharge planning and information
   • The member, member's legal representative or attending physician/provider may request an immediate reconsideration.

Immediate reconsideration
When an initial determination non-certification decision has been made, the member, the member's legal representative or the attending physician/provider may request an immediate reconsideration only if the physician advisor's decision is made during the same business day as the facility's request for inpatient authorization.

If the decision is made the following business day, the attending physician/provider may send in the clinical information for a medical necessity post-service reconsideration and/or provider appeal upon the member's discharge.

If an immediate reconsideration is requested:

1. The clinical case manager involved in the case will contact a second physician advisor, who is a board-certified psychiatrist from the appropriate specialty area and who has not made any previous utilization management opinions regarding the case.
2. The physician advisor, in accordance with the Behavioral Health Department's Standards and Criteria for Utilization Management, will complete a review of the member's case, which may involve analysis of clinical information forwarded by the clinical case manager or speaking directly with the attending physician. NOTE: Physician advisors are not required to attempt direct contact with the attending physician more than 3 times within 24 hours.
3. The physician advisor will give an opinion regarding certification or non-certification of the requested level of care within 24 hours from the time he/she received the immediate reconsideration review request from the clinical case manager. NOTE: In certain cases, Priority Health may extend the determination decision by 48 hours to request additional clinical information from the practitioner/facility.
4. The clinical case manager will provide verbal, written and electronic notification of the physician advisor's decision to the facility and to the member (when applicable) within 24 hours of the request.
   • If further days are certified, the clinical case manager will establish a concurrent review date with the facility.
   • If further days are not certified, the notification letter will include:
   • The principal reason for the non-certification opinion
   • The availability of a physician reviewer to discuss the decision
   • A copy of the criteria upon which the decision was based
   • The right and mechanism for initiating a provider appeal
   Practitioners can obtain this information by contacting the Behavioral Health Department.
   
   • If further days are non-certified based on the lack of medical necessity criteria, the clinical case manager will request that that facility contact Priority Health:
     • If a member's presentation significantly changes
     • With discharge planning and information

Medical necessity post-service reconsideration
A medical necessity post-service reconsideration can occur when a requested level of care has not been certified and the organizational provider has chosen not to exercise his/her right to an immediate reconsideration.

It can also occur when the Priority Health Behavioral Health Department has not wholly reviewed the dates of service in question on a chart that has been submitted for review.

In a medical necessity post-service reconsideration:

1. The complete inpatient record is forwarded to a physician advisor for review.
2. Priority Health will respond to the facility in writing with a decision within 30 calendar days from receipt of the chart (NOTE: Priority Health may extend the determination decision up to 45 days in order to request additional clinical information from the practitioner/facility.)

Provider appeals
A provider may appeal when a requested level of care has not been certified through both an initial determination review and immediate reconsideration review or medical necessity post-service reconsideration.

In either of the above scenarios, the organizational provider may send the complete inpatient record to Priority Health's Behavioral Health Department for an appeal. At that time, the case will be forwarded to the vice president of customer experience and medical operations for review.