Oxford Health Plans > Medical and Administrative Policies > Utilization Management Appeal Process and Timeframes for Connecticut Plans
Title of Policy

Utilization Management Appeal Process and Timeframes for Connecticut Plans

The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage enrollees. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies as well as SecureHorizons and Evercare.

Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.


Policy #: APPEALS 021.11 T0

Coverage Statement:

Policy is applicable to:

    All Connecticut Commercial plans

    Rhode Island residents who are Members of Connecticut Commercial plans

Certain self-funded plans may be excluded from participation in the appeals process. Consult with individual group benefits administrators for specific appeals process.

Note:

  • For Medicare plans, please refer to Oxford policies: Appeals Process for Medicare Plans and Standard and Expedited Complaints & Grievances for Medicare Plans.
  • For the Expedited Appeal Process for Commercial, plans please refer to Oxford policy: Expedited Appeal Process for Commercial Members.


Purpose

This policy identifies Oxford's appeal decision and notification timeframes based on utilization management and denial of claims (post-service) based on medical necessity. This timeframe policy is based on State, Federal, Department of Labor and NCQA guidelines.

A Utilization Management Appeal is an appeal requested after an adverse determination has been rendered on a concurrent or prospective service or claim that required precertification, clinical criteria application and/or medical necessity determination. Notice of the initial adverse determination includes the appropriate appeal rights.


Definitions

Appeal: A request to reverse a utilization management determination not to certify an admission, procedure, service or extension of stay.

Adverse Determination: A determination not to certify, either before, during or after services are received, an admission, service, procedure or extension of stay, or a denial of a claim, because, based on the information provided, the request does not meet Oxford's requirements for medical necessity, appropriateness, health care setting, level of care or effectiveness.

Claim: A request for service or a request for payment including pre-service, concurrent, or post-service benefits.

Claimant: The covered Member or the Member's authorized designee.

Concurrent Care Decision: (continued, extended or additional services) Decisions affecting the ongoing course of treatment over a certain period of time or a number of treatments.

Emergent: Sudden or unexpected onset of severe symptoms which indicate an illness or injury for which treatment may not be delayed without risking the Member's life or seriously impairing the Member's health.

Expedited Review: A modified review process for a claim involving urgent or emergent care. Refer to Oxford policy: Expedited Appeal Process for Commercial Members.

Practitioner: An individual who provides professional health care services, e.g., physicians, nurse practitioners and specialists.

Provider: An institution or organization that provides services to Members, i.e. hospitals, skilled nursing facilities and home care agencies.

Pre-certification (pre-service claim): A request for services (prospective), which requires approval by Oxford, in whole or in part, before the service can be rendered.

Pre-certification (urgent): Requires immediate action, although it may not be a life-threatening circumstance. An urgent situation could seriously jeopardize the life or health of the covered Member or the ability of the Member to re-gain maximum function or, in the opinion of a physician with knowledge of the claimant's condition, would subject the Member to severe pain. An urgent care condition is a situation that has the potential to become an emergency in the absence of treatment.

Retrospective (post-service): Assessing appropriateness of medical services on a case-by-case or aggregate basis after services have been provided such as a claim for services that have already been rendered.


Policy

Who can submit an appeal:

  1. A Claimant can initiate an appeal. A Claimant includes:

    • Member
    • Member's physician with the Member's consent
    • Member's designee or agent (relative, friend or attorney, etc.)

    The Member must provide Oxford with the designation, in writing, at the time of the appeal. The designation must be signed by the Member, or by the Member's guardian, if the Member is a minor.

  2. Participating Provider Appeal

    Participating providers including professional and institutional providers. These appeals are made consistent with the participating provider's contractual obligations with Oxford and are not done on behalf of the Member.

Initiating an Internal Appeal:
There are several methods for submitting an internal appeal.
    In Writing

    • First Level Appeal:

        Oxford Health Plans
        Attn: Clinical Appeals Department
        P.O. Box 7078
        Bridgeport, CT 06601
          Fax: (877) 220-7537

    • Second Level Appeal:

        Oxford Health Plans
        Attn: Grievance Review Board
        48 Monroe Turnpike
        Trumbull, CT 06611
          Fax: 866-352-6053

    Verbally

    • Members: (800) 444-6222
    • Providers: (800) 666-1353

The Clinical Appeals Department and the Grievance Review Board will make all attempts when possible to notify the initiator, in writing, within 5 business days of receipt of the appeal request. An acknowledgment letter will be sent by mail stating that the request for appeal has been received, it is currently being reviewed, and that the initiator will be notified of the outcome.


Procedures and Responsibilities

Appeals rights vary depending on whether it is initiated by the Member or by the provider. In addition, state regulations require different timeframes to be adhered to depending on the level of appeal. All levels of appeal require Oxford to make all attempts when possible to notify the initiator of receipt of the request, in writing, within 5 business days of receipt of the appeal request.

Participating Providers/Facilities appealing regarding Connecticut plan Members:

  • Timeframe for Submission of an Appeal: Participating providers/facilities have 180 days from the initial adverse determination notification, either verbally or by written notification of non-certification, End of Day report issued by Medical Management or Explanation of Benefit statement.
  • Levels of Appeal: Participating providers/facilities have only one level of appeal. Oxford's Clinical Appeals Department will perform a full, clinical review of all pertinent data, including medical records, photos and peer review. This is the final decision for all participating facilities.
  • Decision Timeframe for 1st level Appeals: Participating providers/facilities will be notified in writing of the decision within 60 days from receipt of an appeal and supporting documentation. Full documentation of the substance of the appeal and the actions taken will be maintained in an appeal file.

Member Appeals - Members of Connecticut plans or the authorized designee appealing on behalf of the Member.

  1. First Level Internal Appeal: Clinical Appeals Department

    • Timeframe for Submission of an Appeal:
      Oxford grants all Members 180-calendar days following the Claimant's notification of the initial adverse Utilization Management determination (verbal or written notification of non-certification or Explanation of Benefit statement).

      Clinical Review: Will make all attempts when possible to acknowledge the receipt of the Member's appeal within 5 business days of receipt of the appeal request or respond within this time frame. Oxford will conduct a review of the appeal that does not give regard to the denial decision. Clinical Appeals will fully investigate the substance of the appeal, including any aspects of clinical care involved. The Member will be given an opportunity to submit written comments, documents, medical records, photos, peer review or other information relevant to the appeal. Oxford will appoint an individual to review the appeal who was not involved in the initial decision and is not a subordinate of any person involved in the initial determination. In addition, the person appointed to review the appeal would be a practitioner in the same or similar specialty who typically treats the medical condition, performs the procedure or provides the treatment. All commercial Connecticut plan Members and self-funded Members are entitled to this level. This is the final decision made by Oxford for all self-funded Members unless otherwise requested by the self-funded plan.

    • Decision Timeframe for First Level Appeals
      Oxford must make an appeal determination within:
      • 15 calendar days from receipt of a pre-service appeal
      • 30 calendar days from receipt of a post-service appeal

      The resolution timeframe is calculated from the receipt of the request for a first level appeal. Full documentation of the substance of the appeal, including any aspects of clinical care involved and the actions taken, will be maintained in an appeal file.

    Written appeal decisions must include the following elements, when applicable:

    • The specific reasons for the appeal decision in easily understandable language.
    • A reference to the clinical criteria, benefit provision, guideline, protocol or other similar criterion on which the appeal decision was based, as well as written notification that the Member, upon request, is allowed access to and copies of relevant documentation regarding the Member's appeal. Refer to Oxford's Disclosure Policy.
    • A list of titles and qualifications of individuals participating in the appeal review (participant names do not need to be included in the written notification to Members).
    • A description of the next level of appeal, either within the organization or to an external organization, as applicable, along with any relevant written procedures.

    After all internal levels of appeals have been exhausted (Levels 1 and 2), the Member has the right to file a civil action under 502(a) of the Employee Retirement Income Security Act (ERISA). ERISA rights apply to all Connecticut plans except individuals, church groups and municipalities.

  2. Second Level: Grievance Review Board

    • Timeframe for Submission of a Written Appeal to the Grievance Review Board:
      Members have 60 business days from the First Level utilization management appeal determinations to submit an appeal to the Grievance Review Board.

    • Grievance Review:
      The Second Level Appeal process whereby any Member or any provider acting on behalf of a Member with the Member's consent, who is dissatisfied with the results of the First Level appeal, shall have the opportunity to pursue his or her appeal by submitting a written appeal. Oxford will conduct a review of the appeal that does not give deference to the denial decision. Oxford will fully investigate the substance of the appeal, including any aspects of clinical care involved. The Member will be given an opportunity to submit written comments, documents, medical records, photos, peer review or other information relevant to the Member's appeal to the Grievance Review Board. The Grievance Review Board (GRB) is a team of Oxford employees not involved in the initial determination and who are not the subordinate of any person involved in the initial determination appointed for the express purpose of reviewing and resolving Member appeals. When an appeal is clinical in nature, the GRB will include a licensed physician who did not review the issue at the First Level Appeal. If the appeal pertains to an administrative issue, individuals of a "higher level" than those who reviewed the First Level Appeal will resolve the Second Level Appeal. In addition, one of the persons appointed to review an appeal involving clinical issues is a practitioner in the same or similar specialty who typically treats the medical condition, performs the procedure or provides the treatment.

  3. Decision Timeframe for Grievance Review Board
    • 15 calendar days from the receipt of a pre-service appeal
    • 30 calendar days from the receipt of a post-service appeal

    Written appeal decisions must include the following elements, when applicable:

    • The specific reasons for the appeal decision in easily understandable language.
    • A reference to the clinical criteria, benefit provision, guideline, protocol or other similar criterion on which the appeal decision was based, as well as written notification that the Member, upon request, is allowed access to and copies free of charge of relevant documentation regarding the Member's appeal. Refer to Oxford's Disclosure Policy.
    • A list of titles and qualifications of individuals participating in the appeal review (participant names do not need to be included in the written notification to Members).
    • A description of the next level of appeal, either within the organization or to an external organization, as applicable, along with any relevant written procedures.

    After all internal levels of appeals have been exhausted (First Level and Second Level), the Member has the right to file a civil action under 502(a) of the Employee Retirement Income Security Act (ERISA). ERISA rights apply to all Connecticut plans except individuals, church groups and municipalities.

  4. Member External Appeal Level

    Note: For expedited external appeals, please refer to policy: Expedited Appeal Process for Commercial Members.

    Clinical review conducted by an external agent of the appropriate state. Information on how to submit an external appeal is outlined in the initial denial letter and all subsequent appeal decision letters. All Connecticut commercial plan Members (except self-funded) are entitled to this level, however they must exhaust all internal levels of appeal prior to submitting an external request.

    • Submission timeframe: The submission of an external appeal to the State of Connecticut Insurance Commissioner must be done within 60 calendar days from the date of receipt of the Grievance Review Board Decision. For Rhode Island residents who are Members of Connecticut plans and choose to utilize the State of Rhode Island external appeal process, submission of an external appeal to Oxford must be done within 60 calendar days from the date of receipt of the Grievance Review Board Decision.

    • Decision timeframe: The external review agent will, within five (5) business days of receipt of the request, conduct a preliminary review of the appeal and determine whether to accept it for full review. If the external review agent makes a determination to accept the appeal for full review, it will render a decision within 30 calendar days from the date of such determination. For Rhode Island residents who are Members of Connecticut plans and have chosen to utilize the State of Rhode Island external appeal process, decisions from the external reviewer must be made within 10 business days of the request for standard external appeals and within 2 business days of the request for expedited external appeals. This is the final decision for all Commercial Members.


References:

  1. C.G.S.A. § 38a-226c and §38a-478n.

  2. Regulations of the Connecticut State Agencies Sections 38a-226c-1 et seq. and 38a-487n-3-2 et seq.

  3. General Laws of Rhode Island Annotated §23-17.12-10.

  4. Rhode Island Department of Health Rules and Regulations for the Utilization Review of Health Care Services (R23-17.12-UR).

  5. NCQA Guidelines.

  6. Department of Labor Regulations 29 CFR 2560.503.1.

Effective Date: October 1, 2009 through December 11, 2011