Q. When is a "Utilization Review" conducted?

A. Your managed care plan may conduct a Utilization Review after you or your doctor request approval for treatment. You also have the right to ask for a Utilization Review if you disagree with your plan's decision about whether treatment is medically necessary or about experimental services. This can involve treatments you have already received ("retrospective review"), treatments that you are trying to get ("prospective review"), and treatments you are now getting that you want to continue or get more of ("concurrent review").

Here are some examples of situations where you would ask for a Utilization Review or where your plan may have conducted its own Utilization Review:

• Your plan refuses to pay for a cancer treatment.
• Your plan refuses to pay for cosmetic reconstruction after your mastectomy because it is not "medically necessary."
• Your plan refuses to pay for a special medication that your doctor has ordered because it is not "medically necessary."
• Your plan refuses to authorize an additional day in the hospital that your doctor or you think you need.
• Your plan refuses to let you go to the surgeon that your doctor or you think you should go to.
• Your plan refuses to let you go for physical therapy that your doctor prescribed.

Q. How do you know if your plan has done a "utilization review" of your or your doctor's request for care, and the plan has decided to turn down the request?

A. Your managed care plan must tell you whenever its utilization review staff denies you or your doctor's request for treatment because it is not medically necessary. It must do so within three business days. This is called an "adverse determination." 

Your plan must send you an adverse determination notice, which must explain:

• The reasons why the plan made its decision, including a description of the medical facts on which it based its decision.
• Directions about how to appeal the decision.
• A description of how to get the clinical review criteria (the medical guidelines) that formed the basis of your plan's decision.
• Your right to an external appeal, if the plan rendered a final adverse determination.

Q. How can you appeal your managed care plan's adverse determination?

A. To challenge your plan's "adverse determination," you or your doctor will have to ask for an appeal. A utilization review appeal is an "in-plan process," meaning that your plan's employees (or your plan's sub-contractor)-not independent judges-review your appeal. 

First, call the plan's toll-free "800 number" for Member Services, and tell them that you want to appeal the plan's "adverse determination." By law, your plan must have a system for you to leave a message that you want to file a utilization review appeal if you are calling after regular business hours. 

Always write down the name of the person you spoke to, the date and time you called, and what the plan's Member Services Representative said he or she would do about your utilization review request. 

You may want to ask your doctor to help you appeal your managed care plan's denial of care due to its utilization review.

Q. When would you need to appeal a utilization review decision instead of filing a grievance?

A. Grievances are used when your complaint does not involve a question of medical necessity (for example, a complaint about the attitude of staff or doctors, or getting a bill by mistake).

Q. Why would your plan change its decision? 

A. Medicine is not an exact science, so there are different opinions about the best way to treat a medical condition. Just because your plan starts out saying that you don't need a particular service doesn't mean that it will not change its decision. Many patients win the appeal, once their plan has reviewed their need for care again. Also the appeal has to be decided by a different person from the one who made the original utilization review decision.

When your managed care plan conducts a Utilization Review, it must follow these time frames. If it does not, you automatically win the appeal.

Q. Can your plan change its mind about a decision made during a utilization review of your request for care?

A. Yes, but only in your favor. Once the plan has said it will authorize your care, it cannot change its mind later and make you pay the bill! However, if the decision went against you (an adverse determination), and the plan denied you care, you can ask for an appeal of the utilization review, as described above.

The plan must also reconsider its decision if it did not talk to the doctor who ordered the care for you. In doing this, your plan's utilization review staff must talk to your doctor and issue a new decision within 1 business day. This process is called "reconsideration."

When you "appeal" a Utilization Review decision: 

Q. What happens after you file your utilization review appeal?

A. Your managed care plan may ask you or your doctor to provide additional medical information for its review of the decision. It is important to get them this information as quickly as possible. Always keep proof of the information you sent them. Examples of proof are copies of fax confirmation sheets or return receipt requested forms.

However, if your doctor does not give access to your treatment records, the plan cannot make a decision to deny you care solely because of that.

Q. What information must your managed care plan's decision include?

A. You managed care plan's decision must tell you:

• The reasons for its decision.
• A medical explanation for its decision.
• Your right to file an external appeal with the State Department of Insurance and how to file such an external appeal. 
• If your plan decides to deny coverage for a medical service you and your doctor asked for because it is not medically necessary, you can ask for an external appeal. See Section 5I.5.

Q. Which plan employees are making utilization review decisions and decisions about your appeal?

A. Under State law, managed care plans must hire their own employees or hire a company to make utilization review decisions. These people are called utilization review agents. Utilization review agents must be doctors or licensed health care providers, must be registered with the Commissioner of Health and follow strict standards. For example, only "clinical peer reviewers"-doctors who typically manage the kind of medical condition under review-are allowed to make decisions about whether a treatment is medically necessary.

Your managed care plan's utilization review staff is legally required to:

• be available for you or your doctor to talk to at a toll-free telephone number during normal business hours.
• have a system in place to leave phone messages after business hours. 
• respond to any phone messages within one business day. 
• have its telephone line answered by people trained to take patient information and data over the telephone. 
• supervise telephone staff by medical personnel. 

Remember that the telephone staff cannot decide your case. Only qualified utilization review agents can make decisions related to patient care.

Q. Will your medical records be kept confidential?

A. Yes. All utilization review staff must have written procedures to assure that patient-specific information obtained during the utilization review process is kept confidential and is only shared with you, your representative (if you have one), and your health care providers. 

Utilization review staff may only look at that portion of your medical record which is relevant to the treatment or service issue under review. In addition, the utilization review staff must have your permission before it can contact or interview your family and before it can observe any health service given to you by anyone other than your health care provider. 

A utilization review agent cannot make an adverse determination because your health care provider did not give access to your treatment records.

Q. Can your managed care plan reward its utilization review agent for making adverse determinations?

A. No. The law specifically states that managed care plans and utilization review staff are not permitted to reward employees for making adverse determinations against patients.

Q. Does your managed care plan have to pay for your care even if their utilization review did not approve your care?

A. No. The one exception is emergency care. You are not required to ask for your plan's permission before you use the emergency room or any emergency services.

Q. Should you use other methods to resolve your problem while you appeal an adverse determination?

A. Yes. At any point during and after your appeal, you can call the government offices and health advocates listed at the end of this section to get advice or assistance.