Streamlined medical necessity reviews: What you need to know for timely decisions

• Based on member plans, medical necessity reviews are conducted pre-service, ongoing, or
  post-service.
• Professional reviewers use guidelines to ensure services are medically necessary, with clear decision communication.
• Members can request guidelines, appeal decisions, and access services in their preferred language.

A medical necessity review may be called many things — including utilization review (UR), utilization management (UM), or medical management — within the evidence of coverage or benefit booklet. Requirements for medical necessity review vary based on the member’s benefit plan. Reviews of a medical service may occur:

• When it is requested or planned (prospective or pre-service review).
• During care (inpatient or outpatient ongoing care review).
• After services have been delivered (retrospective or post-service review).

With so many variables, it may help to get a clear picture of what to expect and how the process works.

Timing is important

We are committed to deciding cases quickly and professionally. Here are several time frames you can expect:

Urgent pre-service review requests

An urgent pre-service review request is a request for a pre-service review that, in the view of the treating provider or any physician with knowledge of the member’s medical or behavioral condition, could, without such care and treatment, subject the member to adverse health consequences, pose an imminent and serious threat to the member’s life or health or ability to regain maximum function, or seriously jeopardize the life, health, or safety of the member or others due to the member’s psychological state.

Notification of delay in review determination

If we do not have the information we need to decide, we will try to get it from the physician or other healthcare provider requesting the service, medical procedure, or equipment. If a delay is anticipated because the information is not readily available, we will notify the member and the requesting physician or other healthcare provider in writing. Delay letters include a description of the information we need to decide and specify when the decision can be expected once the information is received. Suppose we do not receive the necessary information. In that case, we will send a final letter explaining that we cannot approve access to benefits due to the lack of the information requested.

We use professional, qualified reviewers

Experienced clinicians review service requests using medical criteria, established guidelines, and applicable medical policies. Requests for covered benefits meeting those standards are certified as medically necessary.

Only a peer clinical reviewer may determine that a service is not medically necessary

Peer clinical reviewers (PCRs) are California-licensed healthcare professionals qualified and clinically competent to evaluate the specific clinical aspects of the request and treatment under review. PCRs are licensed in California and are in the same category as the requesting physician or other healthcare provider. If you are the treating practitioner directly involved in the member’s care/treatment plan and need to discuss a medical necessity review decision, our medical director or PCR is available at 800-794-0838. If the PCR cannot approve a service, the requesting physician, another healthcare provider, or the member has the right to request an appeal.

Decisions not to approve are in writing

Written notice is sent to the member and the requesting physician or other healthcare provider within two business days of the decision. This written notice includes the following:

• A clear and concise explanation of the reason for the decision;
• The name of the criteria and guidelines used to make the decision;
• The name and phone number of the PCR who decided on peer-to-peer discussion;
• Instructions for how to appeal a decision; and
• Specific provisions of the contract exclude coverage if the denial is based on benefit coverage.

Access to criteria

Our Medical Policy and Clinical UM Guidelines for specific services are available to members, member representatives, healthcare providers, and the public. Members may call the number on the back of their ID card for a free copy of the guidelines used to determine their case. The Medical Policy and Clinical UM Guidelines are also available at www.anthem.com/ca. Providers can access UM criteria by selecting the For Providers drop-down at the top of the screen. Under Provider Resources, select Policies, Guidelines & Manuals. Scroll down and select View Medical Policies & UM Guidelines or call 800-794-0838 to request that a paper copy be sent to you. The requested criteria are provided free of charge.

A determination of medical necessity does not guarantee payment or coverage

Determining that services are medically necessary is based on the clinical information provided. Payment is based on a member’s coverage terms at the time of service. These terms include specific exclusions, limitations, and other conditions, as outlined in the member’s evidence of coverage or benefit booklet. Payment of benefits could be limited for several reasons, for example:

• The information submitted with the claim differs from that given at the time of review.
• The service performed is excluded from coverage.
• The member is not eligible for coverage when the service is provided.

Decisions about coverage of service

Our UM decisions are based on the appropriateness of the care and service needed and the member’s coverage according to their health plan. We do not reward providers or other individuals for issuing coverage, service, or care denials. Nor do we make decisions about hiring, promoting, or terminating these individuals based on the idea or thought that they will deny benefits. In addition, we do not offer financial incentives for UM decision-makers to encourage decisions that result in underutilization.

We are available for questions

If you need to request precertification or information about our UM process or have questions or issues, call our toll-free number: 800-274-7767. Our associates are available Monday through Friday (except holidays), 8 a.m. to 5 p.m. PT. If you call after hours or do not reach someone during business hours, you may leave a confidential voicemail message. Please leave your name and phone number; we will return your call by the next business day during the abovementioned hours unless other arrangements are made. Calls received after midnight will be returned the same business day. When making or returning calls, our UM associates identify themselves to all callers by first name, title, and company name. Are there different business hours for FEP? There are no changes.

Language assistance recommends adding that members can call the customer service number on their ID card to request language assistance

For those who request language services, we provide service in the requested language through bilingual staff or an interpreter to help members with their UM issues. Language assistance is provided free of charge. Oral interpretation is available at all points of member contact regarding UM issues. To request language assistance, members can call the toll-free number on the back of their ID card.

TDD/TTY services

A TDD (telecommunications device for people who are deaf or hard of hearing) or TTY (telephone typewriter or teletypewriter) is an electronic device for text communication via a telephone line used when one or more parties have hearing or speech difficulties. If a member has a hearing or speech loss, they can call 711 to use the National Relay Service or 800-855-7100 (English TTY/ English voice) for the California Relay Service. A special operator will contact us to help with the member's needs.

For the Federal Employee Program, the member can call the number on the back of their ID card. We administer UM in California.