A Comprehensive Look at Authorizations, Appeals, & Peer Reviews JULIE KORNACK, ASHLEY WILLIAMS, THEA DAVIS, BRANDON HERSCOVITCH, CATHY BOOTH

Each company should establish their own pricing

If a company refuses to do business, it should be an independent decision

How do we improve outcomes for successful authorizations and appeals?

A1. Deficits in social-emotional reciprocity

A3. Deficits in developing, maintaining, and understanding relationships

B. Restricted, Repetitive Patterns of Behavior, Interests, or Activities

B1. Stereotyped or repetitive motor movements, use of objects, or speech.

B2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change

Autism Resource Center Info Types of Insurance Coverage for ABA Self-funded Private MassHealth Public Fully insured Private *Courtesy of Autism Resource Center

Medical necessity standard in Massachusetts law*: Medical Necessity or Medically Necessary means health care services that are consistent with generally accepted principles of professional medical practice as determined by whether the service is: the most appropriate available supply or level of service for the insured in question considering potential benefits and harms to the individual known to be effective, based on scientific evidence, professional standards and expert opinion, in improving health outcomes based on scientific evidence (for services and interventions not in widespread use) Insurance carriers may develop or use medical necessity criteria (including level of care guidelines), but legal definition controls. *OPP Consumer Protection Regulations, 958 CMR 3.020

Definitions of Medical Necessity

State and Federal mental health parity laws state that there cannot be imposed limits to treatment for Autism including a maximum hour cap.

Recent Supreme Court Decisions in PA have interpreted the that the intention of the State and Federal mental health parity laws is not to prohibit location of where treatment occurs (settings) for autism.

While caregiver participation in the treatment plan plays an important role in a patient s progress, caregiver participation supplements treatment; it doesn t supplant it. Caregivers are not responsible for providing medically necessary treatment.

Adverse Benefit Determination Internal Appeal(s) External Review Court Action Health plan member receives notice of denial Member appeals directly to the health plan *Courtesy of Autism Resource Center If plan upholds denial, external review may be available (voluntary) Member may have cause of action to pursue litigation Copyright 2017 Autism Insurance Resource Center All Rights Reserved

2560.503-1(f)(2)(ii)

Review Agency request External OPP: http://www.mass.gov/anf/docs/hpc/opp/hpc-opp-external-review-form.pdf Island Peer Review Organization (IPRO) Independent Medical Expert Consulting Services (IMEDECS) ProPeer Resources

Retroactive cancellation of coverage (rescission) Adapted from Autism Insurance Resource Center

Provider Letter: Write a letter in support of your patient s appeal, justifying your request. Research: Provide your patient/parent(s) with relevant research to submit with the External Review.

Managed Care Plan (MCPs): In Massachusetts, the Medicaid benefit is administered primarily by the Executive Office of Health and Human Services. Below are the plans : Managed Care Entity (MCE) Mass Behavioral Health Partnership (MBHP) Health New England (HNE) BMCHP Fallon Community Health Plan Neighborhood Health Plan (NHP) Tufts Health Public Plans ABA covered through: Enforcement agency is MassHealth Mass Behavioral Health Partnership (MBHP) Mass Behavioral Health Partnership (MBHP) Beacon Health Options Beacon Health Options Beacon Health Options Tufts Health Public Plans

Consumer Protections Description Examples Appeal to the Medicaid Board of Hearing (BOH) Fair Hearing Denies your provider s request for services. Changes your provider s request for services for example, gives fewer sessions over the same time period or the same number of sessions over a shorter time period. Ends your current service approval

Timelines Description Member Filing Period Decision or Response Deadline Appeal to the Medicaid Board of Hearing (BOH) Fair Hearing 10 Days 45 days Form: https://www.mass.gov/how-to/how-to-appeal-a-masshealth-decision

Stay involved throughout your patient s appeals process. If your patient received a partial authorization, you can use those hours during the appeals process. In fact, most health plans have agreements with regulatory agencies not to reduce hours even if the IRO finds that the health plan awarded too many hours.

Apply to be an External Reviewer panel: MA Link: http://www.imedecs.com/physician-review-form/