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UM 7.5 The managed behavioral healthcare organization
has a procedure for providing independent,
external review of final determinations, including:
Eligibility criteria stating that the MBHO offers
enrollees the right to an independent, third party,
binding review whenever:
- The enrollee is appealing an adverse determination
that is based on medical necessity,
as defined by MBHO.
- The MBHO has completed two levels of internal
reviews and its decision is unfavorable to
the enrollee, or has elected to bypass one or
both levels of internal review or has exceeded
its time limit for internal reviews, without good
cause and without reaching a decision.
- The enrollee has not withdrawn the appeal
request, agreed to another dispute resolution
proceeding, or submitted to an external dispute
resolution proceeding required by law.
- Notification to enrollees about the independent
appeals program and clear and timely
explanations of denials and approvals to
both enrollees and their physicians.
Use of an independent review organization that meets
the following criteria:
- Conducts a thorough review in which it considers
anew all previously determined facts,
allows the introduction of new information,
considers and assesses sound medical
advice, and makes a decision or conclusions
that are not bound by the decisions or conclusions
of the internal appeal.
- Has no material professional, familial, or
financial conflicts of interest with the MBHO.
- MBHO non-interference with the proceedings
of the external review.
- Enrollee exemption from the cost of external
review, including filing fees, and allowance
of designating a representative to act on the
behalf of the enrollee.
- Implementation of independent review organization
decision within specified timeframe.
MBHO data tracking of external appeals for
use in evaluating its medical necessity decision
making process.
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RI 2.2: The network provides a method for resolving
disagreements between the network and the member
or designated decision maker(s) regarding care or
treatment authorization decisions.
The network’s process includes:
- Informing members how to seek appeals of
adverse determinations.
- Defined timeframes in which the member can
anticipate response to an appeal.
- Appeal timeframes that are appropriate to the
urgency of the member’s health care needs.
- An appeal review panel including health care
professionals who are appropriately trained,
experienced, and competent with respect to
the care and treatment involved, and who
were not involved in the initial determination.
- Informing members about further steps available
when disagreements cannot be resolved
through the treatment authorization and
appeal process, such as an internal grievance
process, arbitration, legal proceedings, and
any other external review processes.
RI 5: The network provides for the receipt and
resolution of complaints and grievances from
members in a timely manner.
The member has the right to voice complaints without
fear of recrimination about the care received and to
have complaints reviewed and, whenever possible,
resolved. This right and the way it is protected are
explained to the member. The network has a means
of providing for the following:
- Procedures for registering and managing complaints
and grievances, including identifying
the party receiving complaints and grievances.
- Aggregating and reporting actions taken on
complaints and grievances.
- A timely response to the member, substantively
addressing the action taken on the complaint
or grievance.
- Including the aggregate complaint and grievance
information in performance improvement
activities.
- An appeal process for grievance decisions.
- Member protection from any sanctions or
penalties resulting solely or primarily from
using the complaint or grievance process.
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