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Current Status: Active PolicyStat ID: 3284984

Origination: 05/2017Last Approved: 05/2017Last Revised: 05/2017Next Review: 05/2018Owner: Tasha Bridges: UM Appeals

CoordinatorPolicy Area: Utilization ManagementReferences: NCQA UM 8

Utilization Management/Provider Local andAlternative Dispute Resolution

POLICY

PURPOSE

APPLICATION

KEYWORDS1. Action

2. Alternative Dispute Resolution Hearing

3. Administrative Appeal

4. Adverse Determination

5. Benefit Appeal

6. Expedited Appeal

7. Grievance

It is the policy of Detroit Wayne Mental Health Authority (DWMHA) that uninsured or under insured enrollees/members receiving and practitioners/providers requesting behavioral health services have access to an appealprocess consistent with state and federal requirements.

The purpose of this policy is to provide procedural and operational guidance to DWMHA, Access Center, CrisisService Vendor, Managers of Comprehensive Provider Networks (MCPNs), Contractual staff, Network and Outof Network Providers, uninsured or under insured enrollees/members and all staff involved in utilizationmanagement functions for the development and consistent processing of UM appeals.

This policy applies to DWMHA staff, Access Center, Crisis Service Vendor, Managers of ComprehensiveProvider Networks (MCPNs), Contractual staff. This policy serves all populations:adults children, This policyapplies to DWMHA staff, Crisis Service Vendor staff, Managers of Comprehensive Provider Network (MCPN)staff, Contractual staff. This policy serves all populations: Adults, Children, Adults with Severe Mental Illness(SMI), Children with Serious Emotional Disturbance (SED), Persons with Intellectual/DevelopmentalDisabilities (I/DD) and Persons with Substance Use Disorders (SUD). This policy impacts the uninsured orunder insured enrollee/member.

Utilization Management/Provider Local and Alternative Dispute Resolution. Retrieved 10/04/2017. Official copy athttp://dwmha.policystat.com/policy/3284984/. Copyright © 2017 Detroit Wayne Mental Health Authority

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8. Independent Review Organization (IRO)

9. Medical Necessity Appeal

10. Recipient Rights Complaint

11. Same Specialty

12. Similar Specialty

STANDARDS1. DWMHA, Crisis Service Vendor and/or the MCPNs' UM staff will:

a. Ensure that all local and alternative dispute resolution processes are:

1. Timely;

2. Fair to all parties;

3. Administratively simple;

4. Objective and credible;

5. Accessible and understandable to the enrollee/members and providers;

6. Subject of quality improvement review;

7. Developed in a manner to assure that the individual provider/practitioner who participates in theappeal process on behalf of the enrollee/member are free from discrimination or retaliation;

8. Developed in a manner to assure that they do not interfere with communication between theenrollee/member an the recipient of services;

9. Developed in a manner to assure that an enrollee/member who requests an appeal is free fromdiscrimination or retaliation.

b. Ensure that staff and providers are compliant with the local and alternative dispute resolutionrequirements as evidenced by:

1. Including all necessary language in contracts and requiring contractor's language is incompliance with state and federal requirements;

2. Structuring the local and alternative dispute resolution process that promotes the resolution ofthe enrollee/member's concerns about services;

3. Providing technical assistance and training on the local and alternative dispute resolutionprocess to promote the resolution of concerns as well as support and enhance services;

4. Engaging providers in consultative meetings to provide information and guidance in establishingand implementing the local and alternative dispute resolution policy;

5. Providing standardized documents related to the local and alternative dispute resolution processin the form of templates to providers to customize with their specific identifying information;

6. Ensure all forms related to the local and alternative dispute resolution process are available,easily accessible, understandable and linguistically appropriate to enrollees/members andproviders via websites, Individual Plan of Service meetings and at provider sites;

7. Incorporate a written procedure in operational manuals consistent and compliant with this policy;

8. DWMHA, Crisis Service Vendor and the MCPNs' local and alternative dispute resolution


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materials are compliant with all contractual, regulatory and accreditation requirements inregards to reading level, font, type size, medium and language. Upon request, DWMHA, AccessCenter, Crisis Service Vendor and/or the MCPNs will provide materials in alternative formats tomeet the needs of vision and/or hearing impaired enrollees/members, including large font (atleast 16 point font), Braille and audio formats. Translation services will be provided at no costthe enrollee/member.

c. Provides access to one or more of the following dispute resolution options that may be utilizedsimultaneously:

1. Grievance;

2. Recipient Rights Complaint

d. Provide in writing the Adequate Action Notice form (Uninsured or Under Insured) or the AdvanceAction Notice form (Uninsured or Under Insured) to the enrollee/member and provider in the event ofan adverse action.

e. The form shall include:

1. A statement of what action is being taken in easy, understandable language which does notinclude:

i. abbreviations or acronyms that are not defined; and

ii. is culturally and linguistically sensitive to the enrollee/member's needs; and

iii. health care procedure codes that are not explained.

2. An explanation of the action including the denial of services in amount, scope and duration ifless than what is requested;

3. The specific justification that supports, or the change in the federal or state law that requires theaction including a reference to the benefit provision, guideline, protocol or other similar criterionon which the action is based and the option of the enrollee/member to have a copy of thebenefit provision, guidelines or protocol, upon request;

4. A statement that the enrollee/member and/or provider has a right to a local dispute resolutionreview and a description of the expedited and standard local dispute resolution processincluding time frames;

5. A statement that the enrollee/member, his/her legal representative and/or provider has theopportunity to submit written comments, documents or other information relevant to the localdispute resolution review;

6. A statement that the enrollee/member and/or provider can request copies of all documentsrelevant to the local dispute resolution review, free of charge;

7. Informs the enrollee/member of their right to designate an authorized representative to act ontheir behalf as long as the enrollee/member has provided written permission by completing andforwarding the Appointment of Representative Form or Local Appeal Request Form to DWMHA,Access Center, Crisis Service Vendor or the MCPN;

8. A statement that the expedited or standard local (internal) review must occur prior to theenrollee/member's request for an (external) alternative dispute resolution review with theMichigan Department of Health and Human Services (MDHHS); and

9. Includes a list of the titles and qualifications, including specialties of the individuals participating


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in the appeal review. Name of individual(s) participating in appeal available upon request.

f. The standardized Advance Action Notice form (Uninsured or Under Insured) is sent to the enrollee/member regarding a decision to reduce, suspend or terminate services currently authorized orprovided. The standardized Adequate Action Notice form (Uninsured or Under Insured) is sent to theenrollee/member regarding a decision to deny or limit services being requested.

g. Within ten (10) calendar days of the Notice, the physician and/or provider can verbally or in writingrequest a telephonic peer to peer review before request a 1st level alternative dispute review as longas the enrollee/member has not been discharged from the treatment/services. This is NOTconsidered to be an appeal.

h. For all pre-service and post-service medical necessity and benefit local dispute resolution reviews:

1. DWMHA, Crisis Service Vendor, IRO and/or the MCPN physician shall make reasonableattempts to review telephonically with the treating physician or in any case where a final adverseor adverse action determination is anticipated (i.e. the requested services is not medicallynecessary). The treating physician is expected to comply with these efforts in a timely mannerper his/her contractual review requirements. In those situations where the attending/treatingpractitioner does not comply with the telephonic review, a clinical adverse action determinationmay be rendered.

2. An eligibility, benefit coverage, screening, and/or clinical adverse action determination may onlybe made when the clinical information presented does not meet screening, benefit and/ormedical necessity criteria. The DWMHA, Crisis Service Vendor, IRO and/or MCPN physician orphysician with an addiction-medicine certification must provide written documentation to justifythe eligibility, screening, benefit or clinical adverse action determination, and the documentationmust include an explanation of the next level appeal process. The individual rendering theadverse action determination must have their written signature with credentials on thedocument.

3. DWMHA, Crisis Service Vendor and MCPNs shall provide practitioners with an opportunity todiscuss any UM adverse determinations with a physician reviewer upon request by calling theappropriate UM Department (DWMHA, Crisis Service Vendor or MCPN). .

4. DWMHA, Crisis Service Vendor, IRO and MCPN staff are prohibited from taking any punitiveactions toward a provider who requests a local dispute resolution review.

2. DWMHA, Crisis Service Vendor and the MCPNs UM staff will adhere to the UM Provider AlternativeDispute Resolution Process for the uninsured or under insured enrollee/member:

a. Pre-Service First Level (Redetermination) Medical Necessity or Benefit Local DisputeResolution Review :

1. The provider/practitioner has up to forty five (45) calendar days from the receipt of the Notice torequest a pre-service 1st level (redetermination) medical necessity or benefit internal localdispute resolution review with DWMHA, Crisis Service Vendor or the MCPN. The provider'srequest can be verbal or in writing to DWMHA, Crisis Service Vendor or the MCPN.

i. Adequate Action Notice form (Uninsured or Under Insured)

ii. Advance Action Notice form (Uninsured or Under Insured)

2. All requests for a pre-service 1 st level (redetermination) internal medical necessity or benefitlocal dispute resolution review must include at a minimum the following:


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i. An explanation of what is being disputed and the name, address and telephone number ofthe person responsible for filing the local dispute resolution request; and

ii. Any new additional supporting documentation or evidence such as additional clinicalinformation that has not been previously submitted.

3. The provider's request for a pre-service 1 st level (redetermination) internal medical necessity orbenefit local dispute resolution review can be standard or expedited. An expedited local disputeis a request to review a decision concerning eligibility, benefit coverage, screening, admission,continued/concurrent stay, or other behavioral healthcare services for an enrollee/member whohas received urgent services but has not been discharged from a facility, or when a delay indecision-making might seriously jeopardize an enrollee/member’s life, health, or ability to attain,maintain, or regain maximum function.

4. The provider or enrollee/member can request an expedited 1st level (redetermination) internalmedical necessity or benefit local dispute resolution review within ten (10) calendar days fromreceipt of the Adequate Action Notice form (Uninsured or Under Insured) or the Advance ActionNotice form (Uninsured or Under Insured) as long as the enrollee/member is actively receivingtreatment/services.

5. DWMHA, Crisis Service Vendor or the MCPN will assess any requests for an expedited 1stlevel (redetermination) review and determine if there is clinical rationale that shows the decisionor delay in making the decision may have an adverse impact on the enrollee/member’s healthand well-being. If an expedited request does not meet the expedited criteria, the review requestwill be re-directed through the standard local dispute resolution process and notification mailedto the provider within twenty four (24) hours of the decision to process as a standard review.

6. DWMHA, Crisis Service Vendor and/or the MCPN shall send the standardized Acknowledgmentof Provider Request for a Local Dispute Resolution form (Uninsured or Under Insured) withintwenty four (24) hours of a pre-service expedited 1st level (redetermination) medical necessityor benefit local dispute resolution review request or within five (5) calendar days of a pre-servicestandard 1st level (redetermination) medical necessity or benefit local dispute resolution reviewrequest to the enrollee/member and provider.

7. A physician with the same or similar specialty will review the pre-service 1st level(redetermination) medical necessity or benefit appeal and will not be a subordinate of thephysician who rendered the initial denial.

8. Upon receipt of the pre-service 1st level (redetermination) medical necessity or benefit localdispute review request, the physician will review all documentation submitted and fullyinvestigate all aspects of the clinical care provided without deference to the originaldetermination.

9. The reviewing physician when reviewing a medical necessity local dispute review, in conjunctionwith independent professional medical judgment, will use nationally recognized guidelines,which include but are not limited to, third party guidelines, CMS guidelines, State guidelines,guidelines from recognized professional societies, and advice from authoritative review articlesand textbooks.

10. The physician who made the original denial determination may review the case and overturn theinitial denial.

11. DWMHA, Crisis Service Vendor and/or the MCPN then has seventy two (72) hours from thereceipt of the pre-service expedited 1st level (redetermination) medical necessity or benefit local


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dispute resolution review request to review and make a determination or twenty (20) calendardays from receipt of the pre-service standard 1st level (redetermination) medical necessity orbenefit local dispute resolution review request to review and make a determination.

12. The enrollee/member and/or DWMHA, the Crisis Service Vendor or the MCPN may need to askfor an extension to obtain more information that will assist in the local dispute resolution processusing the standardized Request for Additional Information form (Uninsured or Under Insured)which is sent to the provider and the Enrollee Agreement for Request for Additional Informationform (Uninsured or Under Insured) to the enrollee/member.

13. The enrollee/member and/or DWMHA, Crisis Service Vendor or MCPN may need to ask for anextension to obtain more information that will assist in processing the local dispute. All entitiescan request the necessary information as long as the request is within fourteen (14) calendardays of the original turnaround time frame. If Crisis Service Vendor or the MCPN is requestingthe extension, they must notify the enrollee/member in writing of the request for extension. If theenrollee/member is not in agreement to this extension, he/she may file an expedited oral orwritten grievance with DWMHA, Crisis Service Vendor or the MCPN.

14. A pre-service standard or expedited 1 st level (redetermination) medical necessity or benefitlocal dispute resolution review request that results in upholding part or all of the initial denial iscommunicated verbally to the provider within three (3) hours of the decision. Written notificationusing the standardized Notice of Appeal Decision form (Uninsured or Under Insured) is sent toboth the provider and enrollee/member within twenty four (24) hours of the decision. The onlyexception is when the decision for a pre-service expedited review is made on the last/3rdcalendar day or when the decision is made for a pre-service standard review on the last/20thcalendar day. In these cases, the Notice of Appeal Decision form (Uninsured or UnderInsured) must be mailed on the same day as the determination.

15. The Notice of Appeal Decision form (Uninsured or Under Insured) must include an explanationof how to file a pre-service 2nd level (reconsideration) internal medical necessity or benefit localdispute resolution review request with DWMHA if the determination is to uphold part or all of thenon-authorization of eligibility, benefit coverage, screening, admission, continued/concurrentstay or other behavioral health care services.

16. A DWMHA, Crisis Service Vendor, or MCPN physician is available to discuss a pre-service 1stlevel (redetermination) denial.

b. Pre-Service Second Level (Reconsideration) Medical Necessity or Benefit Local DisputeResolution Review :

1. The provider's request for a pre-service 2nd level (reconsideration) internal medical necessity orbenefit local dispute resolution review request can be verbal or in writing to DWMHA, CrisisService Vendor or the MCPN.

2. The provider's request for a pre-service 2nd level (reconsideration) internal medical necessity orbenefit local dispute resolution review can be standard or expedited.

3. The provider or enrollee/member can request an expedited 2nd level (reconsideration) internalmedical necessity or benefit local dispute resolution review within ten (10) calendar days fromreceipt of the Adequate Action Notice form (Uninsured or Under Insured) or the Advance ActionNotice form (Uninsured or Under Insured) as long as the member is actively receiving treatment/services.

4. The pre-service 2nd level (recoinsderation) medical necessity or benefit local dispute resolution


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review request must include the reason for the request and any additional supportingdocumentation justifying the need for the denied service that has not already been provided aswell as the name, address and telephone number of the person making the request.

5. If Crisis Service Vendor or the MCPN receives a pre-service 2nd level (reconsideration) medicalnecessity or benefit local dispute resolution review request from a provider, Crisis ServiceVendor or the MCPN must notify DWMHA within one (1) hour of receipt of a pre-serviceexpedited 2nd level (reconsideration) request or within one (1) calendar day of receipt of a pre-service standard 2nd level (reconsideration) request. Crisis Service Vendor or the MCPN mustalso forward the complete chart to DWMHA within one (1) hour of receipt of a pre-serviceexpedited 2nd level (reconsideration) request or within one (1) calendar day of receipt of a pre-service standard 2nd level (reconsideration) request.

6. DWMHA will assess any requests for an expedited 2nd level (reconsideration) review anddetermine if there is clinical rationale that shows the decision or delay in making the decisionmay have an adverse impact on the enrollee/member’s health and well-being. If an expeditedrequest does not meet the expedited criteria, the review request will be re-directed through thestandard local dispute resolution process and notification mailed to the provider within twentyfour (24) hours of the decision to process as a standard review.

7. DWMHA shall send a second standardized Acknowledgment of Provider Request for a LocalDispute Resolution form (Uninsured or Under Insured) within twenty four (24) hours of a pre-service expedited 2nd level (reconsideration) medical necessity or benefit local disputeresolution review request or within five (5) calendar days of a pre-service standard 2nd level(reconsideration) medical necessity or benefit local dispute resolution review request to theenrollee/member and provider.

8. The DWMHA Chief Medical Officer or a licensed consultant physician with the same or similarspecialty will review a pre-service 2nd level (reconsideration) medical necessity or benefit localdispute resolution review. Neither will be a subordinate of the physician who rendered the initialor 1st level denial.

9. Upon receipt of the pre-service 2nd level (reconsideration) local dispute review request, thephysician will review all documentation submitted and fully investigate all aspects of the clinicalcare provided without deference to the other two determinations.

10. The reviewing physician when reviewing a medical necessity or benefit local dispute reviewrequest, in conjunction with independent professional medical judgment, will use nationallyrecognized guidelines, which include but are not limited to, third party guidelines, CMSguidelines, State guidelines, guidelines from recognized professional societies, and advice fromauthoritative review articles and textbooks.

11. DWMHA then has seventy two (72) hours from the receipt of the pre-service expedited 2nd level(reconsideration) medical necessity or benefit local dispute resolution review request to reviewand make a determination or ten (10) calendar days from receipt of the pre-service standard2nd level (reconsideration) medical necessity or benefit local dispute resolution review requestto review and make a determination.

12. A pre-service expedited or standard 2 nd level (reconsideration) local dispute resolution reviewrequest that results in upholding part or all of the 1 st level (redetermination) decision iscommunicated verbally to the provider within three (3) hours of the decision. Written notificationusing the standardized Notice of Decision form (Uninsured or Under Insured) is sent to both the


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provider and enrollee/member within twenty four (24) hours of the decision. The only exceptionis when the decision for an pre-service expedited review is made on the last/3rd calendar day orwhen the decision for a pre-service standard review is made on the last/10th day. In either case,the Notice of Appeal Decision form (Under Insured or Uninsured) must be mailed on the sameday as the determination.

13. The second Notice of Appeal Decision form (Uninsured or Under Insured) must include astatement that this is the final internal review level.

14. The second Notice of Appeal Decision form (Uninsured or Under Insured) must also include astatement that the enrollee/member has a right to a request an external Alternative DisputeResolution Hearing with the Michigan Department of Health and Human Services (MDHHS).

15. The request for an external Alternative Dispute Resolution Hearing must be in writing and sentby the uninsured or under insured enrollee/member to:Department of Health and Human ServicesDivision of Program Development, Consultation and ContractsBureau of Community Mental Health ServicesATTN: Request for MDHHS Level Dispute ResolutionLewis Cass Building – 6 th FloorLansing, MI 48193

16. The DWMHA Chief Medical Officer or other physician is available to discuss a pre-service 2ndlevel (reconsideration) denial.

c. Post-Service (Retrospective) First Level (Redetermination) Medical Necessity or Benefit LocalDispute Resolution Review:

1. An eligibility, benefit coverage, screening and/or clinical review of all documentation relevant tothe appeal after the services have been provided is considered a post-service retrospectivereview. The review may be conducted for all or part of the treatment service/or encounter.

2. The provider has up to forty five (45) calendar days from the receipt of the Adequate ActionNotice form (Uninsured or Under Insured) or the Advance Action Notice form (Uninsured orUnder Insured) to request a post-service 1st level (redetermination) medical necessity or benefitinternal local dispute resolution review with DWMHA, Crisis Service Vendor or the MCPN. Theprovider's request must be in writing to DWMHA, Crisis Service Vendor or the MCPN.

3. All requests for a post-service 1 st level (redetermination) internal medical necessity or benefitlocal dispute resolution review must include at a minimum the following:

i. An explanation of what is being disputed and the name, address and telephone number ofthe person responsible for filing the local dispute resolution request; and

ii. The complete medical record (intake, psychiatric evaluation and progress notes, socialwork evaluation and progress notes, nurse evaluation and progress notes, medicationadministration notes and discharge summary).

4. DWMHA, Crisis Service Vendor and/or the MCPN shall send the standardized Acknowledgmentof Provider Request for a Local Dispute Resolution form (Uninsured or Under Insured) withinfive (5) calendar days of a post-service 1st level (redetermination) medical necessity or benefitlocal dispute resolution review request to the enrollee/member and provider.

5. A physician with the same or similar specialty will review the post-service 1st level(redetermination) medical necessity or benefit local dispute resolution review and will not be a


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subordinate of the physician who rendered the initial denial.

6. Upon receipt to the post-service 1st level (redetermination) medical necessity or benefit localdispute resolution review request, the physician will review all documentation submitted andfully investigate all aspects of the clinical care provided without deference to the originaldetermination.


8. DWMHA, Crisis Service Vendor and/or the MCPN then has thirty (30) calendar days fromreceipt of the post-service 1st level (redetermination) medical necessity or benefit local disputeresolution review request to review and make a determination.

9. A post-service 1 st level (redetermination) medical necessity or benefit local dispute resolutionreview request that results in upholding part or all of the initial denial is communicated verballyto the provider within three (3) hours of the decision. Written notification using the Notice ofAppeal Decision Form is sent to both the provider/practitioner and enrollee/member withintwenty four (24) hours of the decision. The only exception is when the decision for a post-service review is made on the last/30th calendar day. In this case, the Notice of Appeal Decisionform (Uninsured or Under Insured) must be mailed on the same day as the determination.

10. The Notice of Appeal Decision form (Uninsured or Under Insured) must include an explanationof how to file a post-service 2nd level (reconsideration) internal medical necessity or benefitlocal dispute resolution review request with DWMHA if the determination is to uphold part or allof the non-authorization of eligibility, benefit coverage, screening, admission, continued/concurrent stay or other behavioral health care services.

11. A DWMHA, Crisis Service Vendor or MCPN physician is available to discuss the post-service1st level (redetermination) denial.

d. Post-Service (Retrospective) Second Level (Reconsideration) Medical Necessity or BenefitLocal Dispute Resolution Review:

1. The provider's request for a post-service 2nd level (reconsideration) internal medical necessityor benefit local dispute resolution review appeal must be in writing to DWMHA, Crisis ServiceVendor or the MCPN.

2. A post-service 2nd level medical necessity or benefit local dispute resolution review requestmust include the reason for the request and any additional supporting documentation justifyingthe need for the denied service as well as the name, address and telephone number of theperson making the request.

3. If Crisis Service Vendor or the MCPN receives a post-service 2nd level (reconsideration)medical necessity or benefit local dispute resolution review request from a provider, CrisisService Vendor or the MCPN must notify DWMHA within one (1) calendar day of receipt of thepost-service 2nd level (reconsideration) request. Crisis Service Vendor or the MCPN must alsoforward the complete chart to DWMHA within one (1) calendar day of receipt of a post-service2nd level (reconsideration) request.

4. DWMHA shall send a second standardized Acknowledgment of Provider Request for a Local


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Dispute Resolution form (Uninsured or Under Insured) within five (5) calendar days of a post-service 2nd level (reconsideration) medical necessity or benefit local dispute resolution reviewrequest to the enrollee/member and provider.

5. The DWMHA Chief Medical Officer or a licensed consultant physician with the same or similarspecialty will review the 2nd level (reconsideration) medical necessity or benefit local disputeresolution review request. Neither will be a subordinate of the physician who rendered the initialor 1st level denial.

6. Upon receipt to the post-service 2nd level (reconsideration) medical necessity or benefit localdispute resolution review request, the physician will review all documentation submitted andfully investigate all aspects of the clinical care provided without deference to the other twodeterminations.


8. DWMHA then has fifteen (15) calendar days from receipt of the post-service 2 nd level(reconsideration) medical necessity or benefit local dispute resolution review request to reviewand make a determination.

9. A post-service 2nd level (reconsideration) medical necessity or benefit local dispute resolutionreview request that results in upholding part or all of the 1st level decision is communicatedverbally to the provider within three (3) hours of the decision. Written notification using a secondstandardized Notice of Appeal Decision form (Uninsured or Under Insured) is sent to both theprovider and enrollee/member within twenty four (24) hours of the decision. The only exceptionis when the decision for a post-service review is made on the last/15th calendar day. In thiscase, the Notice of Appeal Decision form (Uninsured or Under Insured) must be mailed on thesame day as the determination.

10. The second Notice of Appeal Decision form (Uninsured or Under Insured) must include astatement that this is the final internal local dispute resolution review level.

11. The second Notice of Appeal Decision form (Uninsured or Under Insured) must also include astatement that the enrollee/member has a right to a request an external Alternative DisputeResolution Hearing with the Michigan Department of Health and Human Services (MDHHS).

12. The request for an external Alternative Dispute Resolution Hearing must be in writing and sentby the uninsured or under insured enrollee/member to:

Department of Health and Human ServicesDivision of Program Development, Consultation and ContractsBureau of Community Mental Health ServicesATTN: Request for MDHHS Level Dispute ResolutionLewis Cass Building – 6 th FloorLansing, MI 48193

13. The DWMHA Chief Medical Officer or other physician is available to discuss a post-service 2ndlevel (reconsideration) denial.

e. Post-Service (Retrospective) First Level (Redetermination) Administrative Local Dispute


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Resolution Review:

1. The provider has up to forty five (45) calendar days from the receipt of the Adequate ActionNotice form (Uninsured or Under Insured) or the Advance Action Notice form (Uninsured orUnder Insured) to request a post-service 1st level (redetermination) administrative internal localdispute resolution review with DWMHA, Crisis Service Vendor or the MCPN. The provider'srequest must be in writing to DWMHA, Crisis Service Vendor or the MCPN.

2. DWMHA has a one (1) level appeal process for provider/practitioner administrative appeals ofan administrative denial. An example of an administrative denial is failure to authorize servicesin accordance with required time frames.

3. Once the service or procedure has occurred or the enrollee/member has been discharged fromthe facility, the provider/practitioner must utilize the described post-service process in order toappeal.

4. All requests for a post-service 1 st level (redetermination) internal administrative local disputeresolution review must include at a minimum the following:

i. An explanation of what is being disputed and the name, address and telephone number ofthe person responsible for filing the local dispute resolution; andAny additional supporting documentation such as additional clinical information that has notbeen previously submitted as well as well as reason for not meeting DWMHA's notificationtime frames; and

ii. Documentation including the request, reasons why the provider feels the services shouldbe paid and a copy of the claim(s).

5. DWMHA, Crisis Service Vendor or the MCPN shall send the standardized Acknowledgment ofProvider Request for a Local Dispute Resolution form (Uninsured or Under Insured) within five(5) calendar days of receipt of a post-service 1st level (redetermination) administrative localdispute resolution review request to the provider and enrollee/member.

6. The DWMHA UM Appeal Coordinator or designated staff at MCPN or Crisis Service Vendor willreview all documentation submitted with the appeal and determine if appeal is based on medicalnecessity or only on not meeting notification time frames. If appeal based on medical necessity,it will be forwarded to a physician for review, if appeal based on time frames only, then appealwill be forwarded to a Supervisor for review.

7. DWMHA, Crisis Service Vendor and/or the MCPN then has the following time frames to reviewand make a determination:

i. For a post-service 1st level (redetermination) administrative local dispute resolution review,within thirty (30) calendar days of the request.

8. A post-service 1st level (redetermination) administrative local dispute resolution request thatresults in upholding part or all of the initial denial of is communicated verbally to the provider/practitioner within three (3) hours of the decision. Written notification using AdministrativeAppeal Determination Form is sent to both the provider/practitioner and enrollee/member withintwenty four (24) hours of the decision. If the determination is made on the 30th day, then writtennotification will be sent on the same day.

i. Administrative Appeal Determination Form

9. Enrollee/member is held harmless and is given direction on what to do if they receive a bill.


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10. A DWMHA, Crisis Service Vendor, or MCPN professional staff is available to discuss thedenial.

QUALITY ASSURANCE/IMPROVEMENT1. DWMHA shall review and monitor contractor adherence to this policy as one element in its network

management program, and as one element of the QAPIP Goals and Objectives.

2. DWMHA's Quality improvement program must include measures for both the monitoring of and thecontinuous improvement of the programs or processes described in this policy.

3. An Inter-Rater Reliability case review test is conducted by all DWMHA, Crisis Service Vendor and MCPNstaff making UM decisions to ensure consistent application of medical necessity criteria and appropriatelevel of care decisions.

4. Annually, the DWMHA UM Director or his/her designee identifies at least ten (10) vignettes from the Inter-Rater Reliability Indicia MCG module to assess Inter-Rater Reliability system wide.

a. All DWMHA, Crisis Service Vendor and MCPN staff performing UM functions must review thevignettes and select the appropriate level of care by applying the MCG and LCD and NCD UtilizationManagement Criteria.

b. The MCG module immediately generates a compliance report which includes the test scores foreach staff person and an item response analysis and detailed assessment report that pinpoints anyareas the staff need additional training.

c. It is the expectation of DWMHA that staff meet or exceed a score of 90%

d. In the event that a staff person does not met or exceed the 90% threshold, a corrective action planwhich may include such activities as face-to-face supervision, coaching and/or education and re-training is implemented with the expectation that the person pass at the next Inter-Rater Reliabilitycase review test.

5. One additional re-test of at least ten (10) more vignettes will be given within thirty (30) days of the initialInter-Rater Reliability case review test.

a. It is the expectation of DWMHA that the staff person meet or exceed a score of 90%.

b. In the event that the person does not meet or exceed the 90% threshold, he/she will be subject totransfer outside the UM Department or to termination.

6. The results of the Inter-Rater Reliability case review tests will be used to identify areas of variation amongdecision makers and/or types of decisions. The results will also help to identify opportunities forimprovement as well as further training needs. However, all staff performing pre-admission reviews and/orUM functions shall be trained at least annually on the MCG and NCD and LCD Utilization ManagementCriteria.

7. Monthly, Access Center, Crisis Service Vendor and the MCPNs shall forward the complete records/chartsof all (100%) denial and/or appeal cases and the DWMHA Denial and Appeal Master Tracking Log toDWMHA.

8. DWMHA shall then review all of the denial and appeal case records/charts using the Denial Audit tool.

9. Quarterly, Access Center, Crisis Service Vendor and the MCPNs shall review all (100%) denial andappeal case audits for all staff making UM decisions using the DWMHA Access Center Eligibility Reviewtool or the DWMHA Prior Authorized Service UM Review tool.


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10. Quarterly, Access Center, Crisis Service Vendor and SMI MCPN shall also review ten (10) approvedrequest for service cases for all staff making UM decisions. The I/DD MCPNs shall review five (5)approved request for service cases on all staff making UM decisions using the above tools.

11. It is the expectation of DWMHA that all staff from all entities meet or exceed an overall score of 85% orgreater. In the event that a staff person does not meet this threshold of 85% or greater, a corrective actionplan will be implemented with the expectation that the person pass at the next case review. Correctiveaction plans can involve such activities as face to face supervision, coaching and/or education and re-training.

12. If at the next review, the staff person does not achieve 85% or greater, he/she will be subject to transferoutside the UM Department or termination.

13. The results of the audit case reviews will be used to identify areas of variation among decision makersand/or types of decisions. The results will help to identify opportunities for improvement as well as furthertraining needs. However, all staff performing pre-admission reviews and/or UM functions shall be trainedat least annually on the MCG and NCD and LCD Utilization Management Criteria.

COMPLIANCE WITH ALL APPLICABLE LAWS

LEGAL AUTHORITY1. DWMHA UM Program Description FY 16-18

2. MDHHS and DWMHA Contract, October 1, 2016

3. Title II, American with Disabilities Act of 1990, Public Laws 101-336

4. Michigan Mental Health Code, PA 258 of 1974, as amended

5. Michigan Department of Health and Human Services

6. United States Department of Health and Human Services, Office of Civil Rights, Limited EnglishProficiency Policy Guidance, 65 Fed. Reg. 52781

RELATED POLICIES1. Appropriate Professionals for Utilization Management Decision Making Policy

2. Behavioral Health Utilization Management Review Policy

3. Behavioral Health Medical Necessity Policy

4. Customer Service Enrollee/Member Appeal Policy

5. Denial of Service Policy

6. Member Grievance Policy

7. SUD Recipient Rights

8. UM Provider Appeal Policy

DWMHA staff, Access Center staff, Crisis Service Vendor staff, MCPN staff, contractors, and subcontractorsare bound by all applicable local, state and federal laws, rules, regulations and policies, all federal waiverrequirements, state and county contractual requirements, policies, and administrative directives, as amended.


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RELATED DEPARTMENTS1. Clinical Practice Improvement

2. Compliance

3. Customer Service

4. Information Technology

5. Integrated Health Care

6. Managed Care Operations

7. Quality Improvement

8. Recipient Rights

9. Substance Use Disorder

10. Utilization Management

CLINICAL POLICY

INTERNAL/EXTERNAL POLICY

Attachments:

Acknowledgement of Provider Request for LocalDispute Resolution Form (Uninsured or UnderInsured).docxAdequate Action Notice Form (Uninsured orUnder Insured).docxAdministrative Appeal Determination form.docxAdvance Action Notice Form (Uninsured orUnder Insured).docxAppointment of Representative Form.pdfEnrollee Agreement for Request for AdditionalInformation Form (Uinsured or UnderInsured).docxLocal Dispute Request Form (Uninsured orUnder Insured).docNotice of Appeal Decision Form (Uninsured orUnder Insured).docxPost-Service UM Post-Service Provider Localand Alternative Dispute Resolution Proceduresfor Uninsured or Under Insured.docxPre-Service Provider Local and AlternativeDispute Resolution Procedures for Uninsured orUnder Insured.docxRequest for Additional Information Form(Uninsured or Under Insured).docx

Yes

EXTERNAL


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Approval Signatures

Approver Date

Ronald Hocking: Chief Operating Officer 05/2017

Dana Lasenby: Deputy Chief Operating Officer [AS] 05/2017

Allison Smith: Project Manager, PMP 05/2017

Darlene Owens: Director, Substance Use Disorders, Initiatives 05/2017

Julia Kyle: Director of Integrated Care 05/2017

Michele Vasconcellos: Director, Customer Service 05/2017

Lorraine Taylor-Muhammad: Director, Managed Care Operations 04/2017

Bessie Tetteh: CIO 04/2017

Kip Kliber: Director, Recipient Rights 04/2017

William Sabado: Chief of Staff 04/2017

Rolf Lowe: Assistant General Counsel/HIPAA Privacy Officer 04/2017

Stacie Durant: CFO Management & Budget 04/2017

Jody Connally: Director, Human Resources 04/2017

crystal Palmer: Director, Children's Initiatives 04/2017

Corine Mann: Chief Strategic Officer/Quality Improvement 04/2017

Mary Allix 04/2017

Carmen Mcintyre: Chief Medical Officer 04/2017

Sarah Sharp: Consultant 04/2017

Diana Hallifield: Consultant 03/2017

Maha Sulaiman 03/2017

Tasha Bridges: UM Appeals Coordinator 03/2017


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OVERVIEW Procedure Purpose: To provide procedural and operational guidance to all staff involved in utilization

management (UM) functions for the development and consistent processing of pre-service UM/Provider

local and alternative dispute resolution reviews.

Expected Outcome: DWMHA, Crisis Service Vendor, IRO and the MCPNs will be compliant and consistent

in the processing of pre-service UM/Provider local and alternative dispute resolution reviews for

uninsured or under insured enrollee/members.

References: N/A

KEYWORDS


2. Benefit Appeal



PROCEDURE Pre-Service Eligibility, Screening, Benefit or Medically Necessary Appeals: 1. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated

MCPN staff person verbally informs the provider of the determination and sends via mail the standardized Uninsured or Under Insured Advance or Adequate Action Notice form which explains the adverse action including the denial of services in amount, scope and duration if less than what is requested, reason for the adverse action and the local dispute resolution process to the enrollee/member, physician and/or provider. The DWMHA UM Appeal Coordinator, the designated Crisis Service Vendor staff person or designated MCPN staff person documents the date of the Action Notice form in their tracking log and in their electronic system.

2. Within ten (10) calendar days of the date of the Uninsured or Under Insured Adequate or Advance Action Notice form, the physician and/or provider can verbally or in writing request a telephonic peer to peer review before requesting a 1st level (redetermination) local dispute resolution review as long as the enrollee/member has not been discharged from the treatment/services. This is NOT considered to be an appeal.

3. The DWMHA, Crisis Service Vendor, IRO or MCPN physician must make reasonable (at least two) attempts to contact the treating physician within two (2) business days of physician/provider request and document the time and dates of all attempts in the case in their electronic system and their respective tracking log. The treating physician/provider is expected to return the call(s) in a timely manner per the contractual review requirements with DWMHA, Crisis Service Vendor and/or the MCPN. In those instances where the treating physician/provider does not comply with calling back for the telephonic peer to peer review, the denial will stand and the provider will need to file a 1st level local dispute resolution review request by telephone or in writing.

Procedure Title: Pre-Service UM/Provider Local and Alternative Dispute Resolution procedures

Procedure Origination Date: 4/1/17

Procedure Revision Date: 4/1/17

Procedure Owner: Tasha Bridges, LLPC

Department: Utilization Management

Line of Business: Uninsured or Under Insured

Regulatory Requirements: NCQA UM 8, UM 9, Michigan Mental Health Code, PA 258 of 1974, as amended.

Associated Policy: UM Provider Appeals Policy

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Pre-Service 1st Level Redetermination Medical Necessity or Benefit Local Dispute Resolution Review: 1. The physician and/or provider has forty five (45) calendar days from the receipt of the standardized

Uninsured or Under Insured Advance Notice form to request a pre-service 1st level (redetermination) medical necessity internal local dispute resolution review request to DWMHA, Crisis Service Vendor or the MCPN.

2. The provider’s request for a pre-service 1st level (redetermination) medical necessity or benefit internal local dispute resolution review request can be verbal or in writing to DWMHA, Crisis Service Vendor or the MCPN.

3. For all requests for a pre-service 1st level (redetermination) medical necessity or benefit internal local dispute resolution review request, the provider must fax or mail to the DWMHA UM Appeal Coordinator, the designated Crisis Service Vendor staff person or designated MCPN staff person at a minimum the following:

a. An explanation of what is being disputed and the name, address and telephone number of the person responsible for filing the local dispute resolution review request; and

b. Any additional supporting documentation such as additional clinical information that had not been previously submitted.

4. The provider or enrollee/member can request an expedited 1st level (redetermination) medical necessity or benefit internal local dispute resolution review within ten (10) calendar days from receipt of the Uninsured or Under Insured Adequate or Advance Action Notice form as long as the enrollee/member is actively receiving treatment/services.

5. DWMHA, Crisis Service Vendor or the MCPN will assess any requests for an expedited 1st level (redetermination) review and determine if these is clinical rationale that shows the decision or delay in making the decision may have an adverse impact on the enrollee/member’s health and well-being. If an expedited request does not meet the expedited criteria, the review request will be re-directed through the standard local dispute resolution process as a standard review.

6. Upon receipt of the provider’s request for a pre-service 1st level (redetermination) medical necessity or benefit internal local dispute resolution review request, the DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person completes, scans and uploads the standardized Acknowledgement of Provider’s Request for a Local Dispute Resolution for the Uninsured or Under Insured form in the case in their electronic system and then mails it to the provider and enrollee/member within twenty four (24) hours of receipt of a pre-service expedited 1st level (redetermination) medical necessity or benefit internal local dispute resolution review request or within five (5) calendar days of receipt of a pre-service standard 1st level (redetermination) medical necessity or benefit internal local dispute resolution review request.

7. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person must document the date and type (pre-service, medical necessity or benefit and standard or expedited) and method of notification (verbal or written) of the provider’s pre-service 1st level (redetermination) medical necessity or benefit local dispute resolution review request and the date the Acknowledgement of Provider’s Request for a Local Dispute Resolution for the Uninsured or Under Insured form is sent to the provider and enrollee/member in their tracking log and in their electronic system.

8. For a pre-service 1st level (redetermination) medical necessity or benefit local dispute resolution review request, the DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person ensures that the physician who reviews the case is different from and not a subordinate of the physician who made the initial denial decision and that the physician who reviews the case has a similar or same specialty, credentials, licensure and training as those who typically treat the condition or health problem in question. The complete name and credentials of the physician is entered in their tracking log which is used to monitor this.

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9. A determination and written notification of the determination by the DWMHA, Crisis Service Vendor or MCPN physician using the standardized Notice of Appeal Decision for the Uninsured or Under Insured form is required within seventy two (72) hours of receipt of a pre-service expedited 1st level (redetermination) medical necessity or benefit local dispute resolution review request or within twenty (20) calendar days of receipt of a pre-service standard 1st level (redetermination) medical necessity or benefit local dispute resolution review request. The only exceptions are when the decision for a pre-service expedited 1st level (redetermination) local dispute resolution review is made on the last/third (3rd) calendar day or when the decision for a pre-service standard 1st level (redetermination) local dispute resolution review is made on the last/20th calendar day. In these cases, the standardized Notice of Appeal Decision for the Uninsured or Under Insured form must be mailed on the same day as the determination.

10. If the pre-service 1st level (redetermination) medical necessity or benefit local dispute resolution review request is to DWMHA or Crisis Service Vendor, the UM Appeal Coordinator or designated Crisis Service Vendor staff person completes the Physician Referral Review form in MHWIN. Also, any additional information that is sent in with the appeal request is scanned and attached to case in MHWIN. The MHWIN case is then placed in a MHWIN queue for a DWMHA or Crisis Service Vendor physician to review.

11. The DWMHA UM Appeal Coordinator or designated Crisis Service Vendor staff person manually checks the MHWIN queue twice a day to ensure that a DWMHA or Crisis Service Vendor physician has retrieved the case from the queue and reviews it within the appropriate timeframes.

12. For a pre-service expedited 1st level (redetermination) medical necessity or benefit local dispute resolution review, the DWMHA UM Appeal Coordinator or designated Crisis Service Vendor staff person will communicate at a minimum every six (6) hours via email, face to face or telephonically with the DWMHA or Crisis Service Vendor physician reviewer if after the initial six (6) hours, the DWMHA or Crisis Service Vendor physician has not reviewed the case. For a pre-service standard 1st level (redetermination) medical necessity or benefit local dispute resolution review, the DWMHA UM Appeal Coordinator or designated Crisis Service Vendor staff person will communicate daily via email, face to face or telephonically with the DWMHA or Crisis Service Vendor physician reviewer if after the initial seven (7) calendar days the DWMHA or Crisis Service Vendor physician has not reviewed the case. The DWMHA UM Appeal Coordinator or designated Crisis Service Vendor staff person documents all attempts (date and time) to contact the physician in their tracking log. The DWMHA UM Appeal Coordinator, designated Access Center or designated Crisis Service Vendor staff person will use their tracking log as a tool to monitor the timeframes.

13. The MCPNs and IRO staff will follow their own internal procedures to ensure the MCPN or IRO physician reviews the case within the appropriate timeframes. However, the MCPNs will also use their tracking log as a tool to monitor this.

14. The DWMHA or Crisis Service Vendor physician will document their decision in their electronic system (MHWIN) and document their name, title, and credentials if not done by electronic signature.

15. The DWMHA or Crisis Service Vendor physician will then immediately notify via email the DWMHA UM Appeal Coordinator or designated Crisis Service Vendor staff person via email of their decision.

16. The MCPN physician will document the results/decision either in their electronic system or by manually completing a standardized form. The MCPN physician will then immediately notify the designated MCPN staff person according to their internal procedures.

17. The IRO physician will complete the standardized Physician Reviewer Documentation form and immediately fax it to the IRO Medical Review staff. The IRO Medical Review staff will, in turn, immediately email it to the DWMHA UM Appeal Coordinator.

18. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person must document the physician reviewer’s complete name and credentials and the type of decision rendered (approve, deny or split decision), the decision date and the date of the Notice of Appeal Decision for the Uninsured or Under Insured form (if applicable) in their tracking log and in their electronic system.

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19. If the decision is to overturn part or all of the initial denial, the DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person enters the authorization of services in their electronic system within twenty-four (24) hours of determination. Written notification is concurrently sent to the provider and enrollee/member, and a copy of the letter is retained in their electronic system. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person will ensure that written notification is sent to the provider and enrollee/member within seventy-two (72) hours for a pre-service expedited 1st level (redetermination) medical necessity or benefit local dispute resolution or within twenty (20) calendar days of a pre-service standard 1st level (redetermination) medical necessity local dispute resolution.

20. If the decision is to uphold part or all of the initial denial, the DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person verbally notifies the provider within three (3) hours of the decision and documents the date and time of the verbal notification in their tracking log.

21. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person must also document the complete name and credentials of the person to whom the verbal notification was given and the date and time of the verbal notification in the case notes in their electronic system.

22. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person completes the standardized Notice of Appeal Decision for the Uninsured or Under Insured form, scans it and uploads it to the case in their electronic system and then mails it to the provider and enrollee/member within twenty four (24) hours of the decision. The only exceptions are when the decision for a pre-service expedited 1st level (redetermination) local dispute resolution is made on the last/third (3rd) calendar day or when the decision for a pre-service standard 1st level (redetermination) local dispute resolution is made on the last/20th calendar day. In these cases, the Notice of Appeal Decision for the Uninsured or Under Insured form must be mailed on the same day as the determination.

23. If the Notice of Appeal Decision for the Uninsured or Under Insured form is manually generated, the DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or the designated MCPN staff person will scan the Notice and attach it to the case in their electronic system.

24. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person must review the Notice of Appeal Decision for the Uninsured or Under Insured form to ensure the form has the following:

a. A statement of what action is being taken in easy, understandable language which does not include:

abbreviations or acronyms that are not defined; is culturally and linguistically sensitive to the enrollees/members’ needs; and health care procedure codes that are not explained.

b. An explanation of the action including the denial of services in amount, scope and duration if less than what is requested;

c. The specific justification that supports, or the change in the federal or state law that requires the action including a reference to the benefit provision, guideline, protocol or other similar criterion on which the action is based and the option of the enrollee/member to have a copy of the benefit provision, guidelines or protocol, upon request;

d. A statement that the provider has the right to a pre-service 2nd level internal dispute resolution review with DWMHA and a description of the expedited and review process including time frames;

e. Informs the enrollee/member of their right to designate an authorized representative to act on their behalf as long as the enrollee/member has provided written permission by completing and forwarding the standardized Appointment of Representative form to DWMHA, Crisis Service Vendor or MCPN;

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f. A statement that the enrollee/member, his/her legal representative and/or provider can has the opportunity to submit written comments, documents or other information relevant to an appeal;

g. A statement that the enrollee/member and/or provider can request copies of all documents relevant to the appeal, free of charge;

h. A statement that the expedited or standard local (internal) review must occur prior to an the enrollee/member requesting an (external) alternative dispute resolution review with the Michigan Department of Health and Human Services (MDHHS); and

i. Includes a list of the titles and qualifications, including specialties of the individuals participating in the local dispute review.

25. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person documents the date the Notice of Appeal Decision for the Uninsured or Under Insured form (if applicable) is mailed in their tracking log and their electronic system.

Pre-Service 2nd Level Reconsideration Medical Necessity or Benefit Local Dispute Resolution Review: 1. The provider’s request for a pre-service 2nd level (reconsideration) medical necessity or benefit

internal local dispute resolution review can be verbal or in writing to DWMHA, the Crisis Service Vendor or the MCPN.

2. The provider or enrollee/member can request an expedited 2nd level (reconsideration) medical necessity or benefit internal local dispute resolution review within ten (10) calendar days from receipt of the Uninsured or Under Insured Adequate or Advance Action Notice form as long as the enrollee/member is actively receiving treatment/services.

3. If the provider requests a pre-service 2nd level (reconsideration) medical necessity or benefit local dispute resolution review, the DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff documents the date and time, type (pre-service, medical necessity or benefit and standard or expedited) and the method of notification (verbal or written) of the provider’s request in their tracking log and in their electronic system.

4. If the provider requests a pre-service 2nd level (reconsideration) medical necessity or benefit local dispute resolution review to Crisis Service Vendor or the MCPN, the designated Crisis Service Vendor staff person or designated MCPN staff person must forward the provider’s pre-service 2nd level (reconsideration) medical necessity or benefit local dispute resolution review request and the complete clinical case record/documentation via fax to DWMHA’s UM Appeals Coordinator within one (1) hour of receipt of a pre-service expedited 2nd level (reconsideration) request or within one (1) calendar day of receipt of a pre-service standard 2nd level (reconsideration) request.

5. The designated Crisis Service Vendor staff person or designated MCPN staff person must document the date and time, he/she received the provider’s pre-service 2nd level (reconsideration) medical necessity or benefit local dispute resolution request on the fax cover sheet that is sent with the clinical case record in order for the DWMHA UM Appeal Coordinator to document the time and date of the original request in the DWMHA tracking log and in MHWIN (DWMHA’s electronic system).

6. The DWMHA UM Appeal Coordinator then scans and uploads the complete clinical record/documentation in the case in MHWIN.

7. The DWMHA UM Appeal Coordinator documents the date and type (pre-service, medical necessity or benefit and standard or expedited) and method of notification (verbal or written) of the provider’s pre-service 2nd level (reconsideration) local dispute resolution review request in the DWMHA tracking log and in the case in MHWIN.

8. DWMHA will assess any request for an expedited 1st level (redetermination) review and determine if there is clinical rationale that shows the decision or delay in making the decision may have an adverse impact on the enrollee/member’s health and well-being. If an expedited request does not meet the expedited criteria, the review request will be re-directed through the standard local dispute resolution process as a standard review.

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9. Upon receipt of the provider’s request for a pre-service 2nd level (reconsideration) medical necessity or benefit internal local dispute resolution review, the DWMHA UM Appeal Coordinator completes, scans and uploads a second standardized Acknowledgement of Provider’s Request for a Local Dispute Resolution for the Uninsured or Under Insured form in the case in MHWIN and then mails it to the provider and enrollee/member within twenty four (24) hours of receipt of a pre-service expedited 2nd level (reconsideration) medical necessity or benefit internal local dispute resolution review request or within five (5) calendar days of receipt of a pre-service standard 2nd level (reconsideration) medical necessity internal local dispute resolution review request.

10. The DWMHA UM Appeal Coordinator documents the date the second Acknowledgment of Provider’s Request for a Local Dispute Resolution for the Uninsured or Under Insured form was sent to the provider and enrollee/member in the DWMHA tracking log and in the case in MHWIN.

11. For a pre-service 2nd level (reconsideration) medical necessity or benefit local dispute resolution review request, the DWMHA UM Appeal Coordinator ensures that the physician who reviews the case is different from and not a subordinate of the physician who made the 1st level decision and that the physician who reviews the case has a similar or same specialty, credentials, licensure and training as those who typically treat the condition or health problem in question. The complete name and credentials of the physician is entered in the DWMHA tracking log which is used to monitor this.

12. A determination and written notification of the determination by the DWMHA physician using the standardized Notice of Appeal Decision for the Uninsured or Under Insured form is required within seventy two (72) hours of receipt of a pre-service expedited 2nd level (reconsideration) medical necessity or benefit local dispute resolution review request or within ten (10) calendar days of receipt of a pre-service standard 2nd level (reconsideration) medical necessity or benefit local dispute resolution review request. The only exceptions are when the decision for a pre-service expedited 2nd level (reconsideration) local dispute resolution review is made on the last/third (3rd) calendar day or when the decision for a pre-service standard 2nd level (reconsideration) local dispute resolution review is made on the last/10th calendar day. In these cases, the standardized Notice of Appeal Decision for the Uninsured or Under Insured form must be mailed on the same day as the determination.

13. The DWMHA UM Appeals Coordinator completes the Physician Referral Review form in MHWIN. The MHWIN case is then placed in a MHWIN queue for a DWMHA physician to review.

14. The DWMHA UM Appeals Coordinator manually checks the MHWIN queue twice a day to ensure that a DWMHA physician has retrieved the case from the queue and reviews it within the appropriate timeframes.

15. For a pre-service expedited 2nd (reconsideration) medical necessity or benefit local dispute resolution review, the DWMHA UM Appeal Coordinator will communicate at a minimum every six (6) hours via email, face to face or telephonically with the DWMHA physician reviewer if after the initial six (6) hours, the DWMHA physician has not reviewed the case. For a pre-service standard 2nd level (reconsideration) medical necessity or benefit local dispute resolution review, the DWMHA UM Appeal Coordinator will communicate daily via email, face to face or telephonically with the DWMHA physician reviewer if after the initial seven (7) calendar days the DWMHA physician has not reviewed the case. The DWMHA UM Appeal Coordinator documents all attempts (date and time) to contact the physician in the tracking log. The DWMHA UM Appeal Coordinator will use the tracking log as a tool to monitor the timeframes.

16. The IRO staff will follow their own internal procedures to ensure the IRO physician reviews the case within the appropriate timeframes.

17. The DWMHA physician will document their decision in MHWIN and document their name, title, and credentials if not done by electronic signature.

18. The DWMHA physician will immediately notify via email the DWMHA UM Appeal Coordinator via email of their decision.


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20. The DWMHA UM Appeal Coordinator must document the physician reviewer’s complete name and credentials and the type of decision rendered (approve, deny or split decision), the decision date and the date of the Notice of Appeal Decision for the Uninsured or Under Insured form (if applicable) in the DWMHA tracking log and in MHWIN.

21. If the decision is to overturn part or all of the pre-service 1st level (redetermination) medical necessity or benefit decision, the DWMHA UM Appeal Coordinator verbally notifies the designated Crisis Service Vendor staff person or designated MCPN staff person within one (1) hour of the decision. The designated Crisis Service Vendor staff person or the designated MCPN staff person then enters the authorization for services into their electronic system within twenty four (24) hours of the determination. Written notification is concurrently sent to the provider and enrollee/member, and a copy of the notification is retained in their electronic system. The designated Crisis Service Vendor staff person or designated MCPN staff person will ensure that written notification is sent to the provider and enrollee/member within seventy-two (72) hours for a pre-service expedited 2nd level (reconsideration) medical necessity or benefit local dispute resolution or within ten (10) calendar days of a pre-service standard 2nd level (reconsideration) medical necessity or benefit local dispute resolution.

22. If the decision is to uphold part or all of the pre-service 1st level determination, the DWMHA UM Appeal Coordinator verbally notifies the provider within three (3) hours of the decision and documents the date and time of the verbal notification in the DWMHA tracking log.

23. The DWMHA UM Appeal Coordinator must also document the complete name and credentials of the person to whom the verbal notification was given and the date and time of the verbal notification in the case notes in MHWIN.

24. The DWMHA UM Appeal Coordinator completes a second standardized Notice of Appeal Decision for the Uninsured or Under Insured form, scans it and uploads it to the case in MHWIN and then mails it to the provider and enrollee/member within twenty four (24) hours of the decision. The only exceptions are when the decision for a pre-service expedited 2nd level (reconsideration) local dispute resolution is made on the last/3rd calendar day or when the decision for a pre-service standard 2nd level (reconsideration) local dispute resolution is made on the last/10th calendar day. In these cases, the Notice of Appeal Decision for the Uninsured or Under Insured form must be mailed on the same day as the determination.

25. If the second Notice of Appeal Decision for the Uninsured or Under Insured form is manually generated, the DWMHA UM Appeal Coordinator will scan the Notice and attach it to the case in MHWIN.

26. The DWMHA UM Appeal Coordinator must review the second Notice of Appeal Decision for the Uninsured or Under Insured form to ensure the form includes the following:



b. An explanation of the action including the denial of services in amount, scope and duration if less than what is requested;

c. The specific justification that supports, or the change in the federal or state law that requires the action including a reference to the benefit provision, guideline, protocol or other similar criterion on which the action is based and the option of the enrollee/member to have a copy of the benefit provision, guidelines or protocol, upon request;

d. A statement that this is the final internal level of review; e. A statement that the enrollee/member has a right to an Alternative Dispute Resolution

Hearing with the Michigan Department of Health and Human Services (MDHSS) with an explain of the process; and

f. Includes a list of the titles and qualifications, including specialties of the individuals participating in the local dispute review.

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27. The designated Crisis Service Vendor staff person and designated MCPN staff person forwards via email their complete tracking log to the DWMHA UM Appeals Coordinator by the 10th of each month for compliance monitoring.

PROCEDURE MONITORING & STEPS Who monitors this procedure: DWMHA UM Appeal Coordinator


Frequency of monitoring: Monthly

Reporting provided to: Director of UM

Regulatory Requirement(s): NCQA-UM 8 &9 and the Medicaid State Contract, October 1, 2016

MONITORING STEPS

1. The designated Crisis Service Vendor staff person and designated MCPN staff person must forward

via email their completed standardized tracking log to the DWMHA UM Appeals Coordinator by the

10th of each month for compliance monitoring. In addition, a copy of the appeal case is forwarded to

the DWMHA UM Appeals Coordinator for purpose of performing an audit to ensure the case was

processed in accordance with the UM Provider Local and Alternative Dispute Resolution Policy and

Procedures.

2. Appeal and denial audit tools are used to audit 100% of the cases.

3. The results of the monthly audits will be reported to the DWMHA UM Director as well as to the

designated Crisis Service Vendor or designated MCPN staff member.

4. Quarterly results of the audits will be presented to the Utilization Management Committee (UMC).

5. For any cases scoring less than 85%, one on one review of the case will be done by the DWMHA UM

Appeal Coordinator to either the designated Crisis Service Vendor or MCPN staff member.

6. If any cases score less than 85% on the audit for three (3) consecutive months, Crisis Service Vendor

or MCPN will be placed on a corrective action plan (CAP).

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OVERVIEW Procedure Purpose: To provide procedural and operational guidance to all staff involved in utilization

management functions for the development and consistent processing of Post-Service UM/Provider

(retrospective) local and alternative dispute resolution reviews.

Expected Outcome: : DWMHA, Crisis Service Vendor, IRO and the MCPNs will be compliant and consistent

in the processing of post-service UM/Provider local and alternative dispute resolution reviews for

uninsured or under insured enrollee/members.

References: N/A

KEYWORDS


2. Benefit Appeal



PROCEDURE Post-Service Eligibility, Screening, Benefit or Medically Necessary Appeals: 1. The DWMHA UM Appeal Coordinator or designated Crisis Service Vendor staff person or designated

MCPN staff person verbally informs the provider of the determination and sends via mail the standardized Uninsured or Under insured Advance or Adequate Action Notice which explains the adverse action including the denial of service in amount, scope and duration less than what was requested, reason for the adverse action and local dispute resolution process to the enrollee/member, physician and/or provider. The DWMHA UM Appeal Coordinator, the designated Crisis Service Vendor staff person or designated MCPN staff person documents the date of the Action Notice form in their tracking log and in their electronic system.

Post-Service 1st Level Redetermination Medical Necessity or Benefit Local and Alternative Dispute Resolution Review: 1. The physician and/or provider has forty five (45) calendar days from the date of the standardized

Uninsured or Under insured Adequate or Advance Action Notice form to request a post-service 1st level (redetermination) medical necessity or benefit internal local dispute resolution review to Crisis Service Vendor or the MCPN.

2. The provider’s request for a post-service 1st level (redetermination) medical necessity or benefit internal local dispute resolution review must be in writing to DWMHA, Crisis Service Vendor or the MCPN.

Procedure Title: Post-Service UM Provider Local and Alternative Dispute Resolution Procedure

Procedure Origination Date: 4/1/17

Procedure Revision Date: 4/1/17

Procedure Owner: Tasha Bridges, LLPC


Line of Business: Uninsured or Under insured

Regulatory Requirements: NCQA UM 8, UM 9, Michigan Mental Health Code, PA 258 of 1974, as amended.

Associated Policy: UM Provider Local and Alternative Dispute Resolution Policy

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3. For all requests for a post-service 1st level (redetermination) medical necessity or benefit internal local dispute resolution review, the provider must fax or mail to the DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person at a minimum the following:

a. An explanation of what is being disputed and the name, address and telephone number of the person responsible for filing the Local and Alternative Dispute Resolution request; and

b. The complete medical record (at a minimum the intake, psychiatric evaluation, psychiatric progress notes, social work evaluation, social work progress notes, nurse evaluation, nurse progress notes, medication administration notes and discharge summary) if not provided previously; and

c. Any additional supporting documentation that has not been previously submitted. 4. Upon receipt of the provider’s request for a 1st level (redetermination) medical necessity or benefit local

dispute resolution review, the DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person completes, scans and uploads the standardized Acknowledgement of Provider’s Request for a Local Dispute Resolution for the Uninsured or Under Insured form in their electronic system and then mails it to the provider and enrollee/member within five (5) calendar days of receipt of a post-service 1st level (redetermination) medical necessity or benefit internal local dispute resolution review request.

5. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person must document the date, time, type (post-service, medical necessity or benefit, standard) and the method of notification (written) of the post-service 1st level (redetermination) medical necessity or benefit local dispute resolution request and the date the Acknowledgement of Provider’s Request for a Local Dispute Resolution for the Uninsured or Under Insured form is sent to the provider and enrollee/member in their tracking log and their electronic system.

6. For a post-service 1st level (redetermination) medical necessity or benefit local dispute resolution review request, the DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person ensures that the physician who reviews the case is different from and not a subordinate of the physician who made the initial denial decision and that the physician who reviews the case has a similar or same specialty, credentials, licensure and training as those who typically treat the condition or health problem in question. The complete name and credentials of the physician is entered in their tracking log which is used to monitor this.

7. A determination and written notification of the determination by the DWMHA, Crisis Service Vendor or MCPN physician is required within thirty (30) calendar days of receipt of a post-service 1st level (redetermination) medical necessity or benefit local dispute resolution review request. The only exception is when the decision for a post-service 1st level (redetermination) local dispute resolution review is made on the last/30th calendar day. In this case, the standardized Notice of Appeal Decision for the Uninsured or Under Insured form must be mailed on the same day as the determination.

8. If the post-service 1st level (redetermination) medical necessity or benefit local dispute resolution review request is to DWMHA or Crisis Service Vendor, the DWMHA UM Appeal Coordinator or designated Crisis Service Vendor staff person completes the Physician Referral Review form in MHWIN. Also, any additional information that is sent in with the appeal request is scanned and attached to case in MHWIN. The MHWIN case is then placed in a MHWIN queue for a DWMHA or Crisis Service Vendor physician to review.

9. The DWMHA UM Appeal Coordinator or designated Crisis Service Vendor staff person manually checks the MHWIN queue twice a day to ensure that a DWMHA or Crisis Service Vendor physician has retrieved the case from the queue and reviews it within the appropriate timeframe.

10. For a post-service 1st level (redetermination) medical necessity or benefit local dispute resolution review, the DWMHA UM Appeal Coordinator or designated Crisis Service Vendor staff person will communicate via email, face to face or telephonically with the DWMHA or Crisis Service Vendor physician reviewer if after the initial seven (7) calendar days the DWMHA or Crisis Service Vendor physician has not reviewed the case.

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11. The MCPNs and IRO staff will follow their own internal procedures to ensure the MCPN or IRO physician reviews the case within the appropriate timeframes. However, the MCPNs will also use their tracking log as a tool to monitor this.

12. The DWMHA or Crisis Service Vendor physician will document their decision in their electronic system (MHWIN) and document their name, title, and credentials if not done by electronic signature.

13. The DWMHA or Crisis Service Vendor physician will then immediately notify via email the DWMHA UM Appeal Coordinator or designated Crisis Service Vendor staff person via email of their decision.

14. The MCPN physician will document the results/decision either in their electronic system or by manually completing a standardized form. The MCPN physician will then immediately notify the designated MCPN staff person according to their internal procedures.


16. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person must document the physician reviewer’s complete name and credentials and the type of decision rendered (approve, deny or split decision), the decision date and the date of the Notice of Appeal Decision for the Uninsured or Under Insured form (if applicable) in their tracking log and in their electronic system.

17. If the decision is to overturn part or all of the initial denial, the DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person enters the authorization of services in their electronic system within twenty-four (24) hours of determination. Written notification is concurrently sent to the provider and enrollee/member, and a copy of the letter is retained in their electronic system. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person will ensure that written notification is sent to the provider and enrollee/member within thirty (30) calendar days of a post-service 1st level (redetermination) medical necessity or benefit local dispute resolution.

18. If the decision is to uphold part or all of the initial denial, the DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person verbally notifies the provider within three (3) hours of the decision and documents the date and time of the verbal notification in their tracking log.

19. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person must also document the complete name and credentials of the person to whom the verbal notification was given and the date and time of the verbal notification in the case notes in their electronic system.

20. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person completes the standardized Notice of Appeal Decision for the Uninsured or Under Insured form, scans it and uploads it to the case in their electronic system and then mails it to the provider and enrollee/member within twenty four (24) hours of the decision. The only exception is when the decision for a post-service 1st level (redetermination) local dispute resolution is made on the last/30th calendar day. In this case, the Notice of Appeal Decision for the Uninsured or Under Insured form must be mailed on the same day as the determination.

21. If the Notice of Appeal Decision for the Uninsured or Under Insured form is manually generated, the DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person will scan the Notice and attach it to the case in their electronic system.

22. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN staff person must review the Notice of Appeal Decision for the Uninsured or Under Insured form to ensure it has the following:



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b. An explanation of the action including the denial of services in amount, scope and duration if lessthan what is requested;

c. The specific justification that supports, or the change in the federal or state law that requiresthe action including a reference to the benefit provision, guideline, protocol or other similarcriterion on which the action is based and the option of the enrollee/member to have a copy ofthe benefit provision, guidelines or protocol, upon request;

d. A statement that the provider has the right to a post-service 2nd level internal dispute resolutionreview with DWMHA and a description of the review process including time frames;

e. Informs the enrollee/member of their right to designate an authorized representative to act ontheir behalf as long as the enrollee/member has provided written permission by completing andforwarding the standardized Appointment of Representative form to DWMHA, Crisis ServiceVendor or MCPN;

f. A statement that the enrollee/member, his/her legal representative and/or provider has theopportunity to submit written comments, documents or other information relevant to an appeal;

g. A statement that the enrollee/member and/or provider can request copies of all documentsrelevant to the appeal, free of charge;

h. A statement that the expedited or standard local (internal) review must occur prior to an theenrollee/member requesting an (external) alternative dispute resolution review with theMichigan Department of Health and Human Services (MDHHS); and

i. Includes a list of the titles and qualifications, including specialties of the individuals participatingin the local dispute review.

23. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPNstaff person documents the date the Notice of Appeal Decision for the Uninsured or Under Insured form(if applicable) is mailed in their tracking log and their electronic system.

Post-Service 2nd Level Reconsideration Medical Necessity or Benefit Appeal Local Dispute Resolution Review: 1. The provider’s request for a post-service 2nd level (reconsideration) medical necessity or benefit internal

local dispute resolution review must be in writing.2. If the provider requests a post-service 2nd level (reconsideration) medical necessity or benefit local

dispute resolution review, the DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staffperson or designated MCPN staff documents the date and time, type (post-service, medical necessity orbenefit and standard) and the method of notification (written) of the provider’s request in their trackinglog and in their electronic system.

3. If the provider requests a post-service 2nd level (reconsideration) medical necessity or benefit localdispute resolution review to Crisis Service Vendor or the MCPN, the designated Crisis Service Vendorstaff person or designated MCPN staff person must forward the provider’s post-service 2nd level(reconsideration) medical necessity or benefit local dispute resolution review request and the completeclinical case record/documentation via fax to DWMHA’s UM Appeals Coordinator within one (1) calendarday of receipt of a post-service 2nd level (reconsideration) request.

4. The designated Crisis Service Vendor staff person or designated MCPN staff person must document thedate and time, he/she received the provider’s post-service 2nd level (reconsideration) medical necessityor benefit local dispute resolution request on the fax cover sheet that is sent with the clinical case recordin order for the DWMHA UM Appeal Coordinator to document the time and date of the original requestin the DWMHA tracking log and in MHWIN (DWMHA’s electronic system).

5. The DWMHA UM Appeals Coordinator then scans and uploads the complete clinicalrecord/documentation in the case in MHWIN.

6. The DWMHA UM Appeal Coordinator documents the date and type (post-service, medical necessity orbenefit and standard) and method of notification (written) of the provider’s post-service 2nd level(reconsideration) local dispute resolution review request in the DWMHA tracking log and in the case inMHWIN.

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7. Upon receipt of the provider’s request for a post-service 2nd level (reconsideration) medical necessity or benefit internal local dispute resolution review request, the DWMHA UM Appeal Coordinator completes, scans and uploads a second standardized Acknowledgement of Provider’s Request for a Local Dispute Resolution for the Uninsured or Under Insured form in the case in MHWIN and then mails it to the provider and enrollee/member within five (5) calendar days of receipt of a post-service 2nd level (reconsideration) medical necessity or benefit internal local dispute resolution review request.

8. The DWMHA UM Appeal Coordinator documents the date the second Acknowledgment of Provider’s Request for a Local Dispute Resolution for the Uninsured or Under Insured form was sent to the provider and enrollee/member in the DWMHA tracking log and in the case in MHWIN.

9. For a post-service 2nd level (reconsideration) medical necessity or benefit local dispute resolution review request, the DWMHA UM Appeal Coordinator ensures that the physician who reviews the case is different from and not a subordinate of the physician who made the 1st level decision and that the physician who reviews the case has a similar or same specialty, credentials, licensure and training as those who typically treat the condition or health problem in question. The complete name and credentials of the physician is entered in the DWMHA tracking log which is used to monitor this.

10. A determination and written notification of the determination by a DWMHA physician is required within fifteen (15) calendar days of receipt of a post-service 2nd level (reconsideration) medical necessity or benefit local dispute resolution review request. The only exception is when the decision for a post-service 2nd level (reconsideration) local dispute resolution review is made on the last/15th calendar day. In this case, the standardized Notice of Appeal Decision for the Uninsured or Under Insured form must be mailed on the same day as the determination.

11. The DWMHA UM Appeals Coordinator completes the Physician Referral Review form in MHWIN. The MHWIN case is then placed in a MHWIN queue for a DWMHA physician to review.

12. The DWMHA UM Appeals Coordinator manually checks the MHWIN queue twice a day to ensure that a DWMHA physician has retrieved the case from the queue and reviews it within the appropriate timeframe.

13. For a post-service 2nd (reconsideration) medical necessity or benefit local dispute resolution review, the DWMHA UM Appeal Coordinator will communicate daily via email, face to face or telephonically with the DWMHA physician reviewer if after the initial seven (7) calendar days the DWMHA physician has not reviewed the case.

14. The IRO staff will follow their own internal procedures to ensure the IRO physician reviews the case within the appropriate timeframes.

15. The DWMHA physician will document his/her decision in MHWIN and document their name, title, and credentials if not done by electronic signature.

16. The DWMHA physician will immediately notify via email the DWMHA UM Appeal Coordinator via email of their decision.


18. The DWMHA UM Appeals Coordinator documents the physician reviewer complete name and credentials and the type of decision rendered (approve, deny or split decision), the decision date and the date of the Notice of Appeal Decision for the Uninsured or Under Insured form (if applicable) in the DWMHA tracking log and in MHWIN.

19. If the decision is to overturn part or all of the post-service 1st level (redetermination) medical necessity or benefit decision, the DWMHA UM Appeal Coordinator verbally notifies the designated Crisis Service Vendor staff person or designated MCPN staff person within one (1) hour of the decision. The designated Crisis Service Vendor staff person or the designated MCPN staff person then enters the authorization for services into their electronic system within twenty four (24) hours of the determination. Written notification is concurrently sent to the provider and enrollee/member, and a copy of the notification is

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retained in their electronic system. The designated Crisis Service Vendor staff person or designated MCPN staff person will ensure that written notification is sent to the provider and enrollee/member within fifteen (15) calendar days of a post-service 2nd level (reconsideration) medical necessity or benefit local dispute resolution.

20. If the decision is to uphold part or all of the post-service 1st level (redetermination) medical necessity orbenefit decision, DWMHA UM Appeal Coordinator verbally notifies the provider within three (3) hoursof the decision and documents the date and time of the verbal notification in the DWMHA tracking log.

21. The DWMHA UM Appeal Coordinator must also document the complete name and credentials of theperson to whom the verbal notification was given and the date and time of the verbal notification in thecase notes in MHWIN.

22. The DWMHA UM Appeal Coordinator completes a second standardized Notice of Appeal Decision forthe Uninsured or Under Insured form, scans it and uploads it to the case in MHWIN and then mails it tothe provider and enrollee/member within twenty four (24) hours of the decision. The only exception iswhen the decision for a post-service 2nd level (reconsideration) local dispute resolution is made on thelast/15th calendar day. In this case, the Notice of Appeal Decision for the Uninsured or Under Insuredform must be mailed on the same day as the determination.

23. If the second Notice of Appeal Decision for the Uninsured or Under Insured form is manually generated,the DWMHA UM Appeal Coordinator will scan the Notice and attach it to the case in MHWIN.

24. The DWMHA UM Appeal Coordinator must review the second Notice of Appeal Decision for theUninsured or Under Insured form to ensure it has the following:

a. A statement of what action is being taken in easy, understandable language which does notinclude:




d. A statement that this is the final internal level of review;e. A statement that the enrollee/member has a right to an Alternative Dispute Resolution Hearing

with the Michigan Department of Health and Human Services (MDHSS) with an explain of theprocess; and

f. Includes a list of the titles and qualifications, including specialties of the individuals participatingin the local dispute review.

25. The designated Crisis Service Vendor staff person and designated MCPN staff person forwards via emailtheir complete tracking log to the DWMHA UM Appeals Coordinator by the 10th of each month forcompliance monitoring.

Post-Service Provider Administrative Appeal: 1. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPN

staff person verbally informs the physician and/or provider of the determination and sends via mail thestandardized Uninsured or Under Insured Adequate or Advance Action Notice form which explains theadverse action, reason for the adverse action (administrative reasons) and the appeal process to theenrollee/member, physician and/or provider. The DWMHA UM Appeal Coordinator, the designatedCrisis Service Vendor staff person or designated MCPN staff person documents the date of the ActionNotice form in their tracking log and in their electronic system. .

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Post-Service 1st Level Redetermination Provider Administrative Local Dispute Resolution Review: 1. The physician and/or provider has forty five (45) calendar days from the receipt of the standardized

Uninsured or Under Insured Advance Notice form to request a post-service 1st level (redetermination)administrative internal local dispute resolution review request to DWMHA, Crisis Service Vendor or theMCPN.

2. The provider's request for a post-service 1st level (redetermination) administrative internal local disputeresolution review request must be in writing to DWMHA, Crisis Service Vendor or the MCPN.

3. For all requests for a post-service 1st level (redetermination) administrative internal local disputeresolution review request, the provider must fax or mail to the DWMHA UM Appeal Coordinator,designated Crisis Service Vendor staff person or designated MCPN staff person at a minimum thefollowing:

An explanation of what is being disputed and the name, address and telephone number of theperson responsible for filing the local dispute resolution review request; and

Any additional supporting documentation such as additional clinical information that had notbeen previously submitted; and

Documentation including the request, reasons why the provider feels the services should be paidand a copy of the claim(s).

4. Upon receipt of the provider’s request for a post-service 1st level (redetermination) administrativeinternal local dispute resolution review request, the DWMHA UM Appeal Coordinator, designated CrisisService Vendor staff person or designated MCPN staff person completes, scans and uploads thestandardized Acknowledgement of Provider’s Request for a Local Dispute Resolution for the Uninsuredor Under Insured form in the case in their electronic system and then mails it to the provider andenrollee/member within five (5) calendar days of receipt of a post-service 1st level (redetermination)administrative internal local dispute resolution review request.

5. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPNstaff person must document the date and type (post-service, administrative and standard) and methodof notification (written) of the provider’s post-service 1st level (redetermination) administrative localdispute resolution review request and the date the Acknowledgement of Provider’s Request for a LocalDispute Resolution for the Uninsured or Under Insured form is sent to the provider andenrollee/member in their tracking log and in their electronic system.

6. For a post-service 1st level (redetermination) administrative local dispute resolution review request, theDWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPNstaff person ensures that the Professional staff person who reviews the case is different from theProfessional staff person who made the initial denial decision. The complete name and credentials ofthe Professional staff person is entered in their tracking log which is used to monitor this.

7. A determination and written notification of the determination by DWMHA, Crisis Service Vendor or theMCPN Professional staff person is required within thirty (30) calendar days of receipt of a post-service1st level (redetermination) administrative local dispute resolution review request. The only exception iswhen the decision for a post-service 1st level (redetermination) local dispute resolution review is madeon the last/30th calendar day. In this case, the standardized Notice of Appeal Decision form must bemailed on the same day as the determination.

8. If the post-service 1st level (redetermination) administrative local dispute resolution review request is toDWMHA or Crisis Service Vendor, the DWMHA UM Appeal Coordinator or designated Crisis ServiceVendor staff person forwards via email or face to face the administrative appeal request to the DWMHAor Crisis Service Vendor UM Supervisor or designee for review and determination.

9. If the post-service 1st level (redetermination) administrative review request is to one of the MCPNs, theMCPN follows their internal process to ensure a determination and written notification is completedwithin the appropriate timeframe.

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10. The DWMHA, Crisis Service Vendor or MCPN UM Supervisor or designee will document their decision intheir electronic system and document their name, title, and credentials if not done by electronicsignature.

11. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPNstaff person must document the complete name and credentials of DWMHA, Crisis Service Vendor orMCPN UM Supervisor or designee and the type of decision rendered (approve, deny or split decision),the decision date and the date of the Notice of Appeal Decision form (if applicable) in their tracking logand in their electronic system.

12. If the decision is to overturn part or all of the initial denial, the DWMHA UM Appeal Coordinator,designated Crisis Service Vendor staff person or designated MCPN staff person enters the authorizationof services in their electronic system within twenty-four (24) hours of determination. Writtennotification is concurrently sent to the provider and enrollee/member, and a copy of the letter isretained in their electronic system. The DWMHA UM Appeal Coordinator, designated Crisis ServiceVendor staff person or designated MCPN staff person will ensure that written notification is sent to theprovider and enrollee/member within thirty (30) calendar days of a post-service 1st level(redetermination) administrative local dispute resolution.

13. If the decision is to uphold part or all of the initial denial, the DWMHA UM Appeal Coordinator,designated Crisis Service Vendor staff person or designated MCPN staff person verbally notifies theprovider within three (3) hours of the decision and documents the date and time of the verbalnotification in their tracking log.

14. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPNstaff person must also document the complete name and credentials of the person to whom the verbalnotification was given and the date and time of the verbal notification in the case notes in theirelectronic system.

15. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPNstaff person completes the standardized Notice of Appeal Decision for the Uninsured or Under Insuredform, scans it and uploads it to the case in their electronic system and then mails it to the provider andenrollee/member within twenty four (24) hours of the decision. The only exception is the decision for apost-service 1st level (redetermination) is made on the last/30th calendar day. In this case, the Notice ofAppeal Decision for the Uninsured or Under Insured form must be mailed on the same day as thedetermination.

16. If the Notice of Appeal Decision for the Uninsured or Under Insured form is manually generated, theDWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or the designated MCPNstaff person will scan the Notice and attach it to the case in their electronic system.

17. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPNstaff person must review the Notice of Appeal Decision for the Uninsured or Under Insured form toensure it has the following:

a. A statement of what action is being taken in easy, understandable language which does notinclude:




d. Informs the enrollee/member of their right to designate an authorized representative to act ontheir behalf as long as the enrollee/member has provided written permission by completing andforwarding the standardized Appointment of Representative form to DWMHA, Crisis ServiceVendor or MCPN;

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e. A statement that the enrollee/member, his/her legal representative and/or provider has theopportunity to submit written comments, documents or other information relevant to an appeal;

f. A statement that the enrollee/member and/or provider can request copies of all documentsrelevant to the appeal, free of charge;

g. A statement that this is the only and final internal review level for an administrative local disputereview request.

h. A statement that local (internal) review must occur prior to the enrollee/member requesting an(external) alternative dispute resolution review with the Michigan Department of Health andHuman Services (MDHHS).

i. Includes a list of the titles and qualifications, including specialties of the individuals participatingin the local dispute review.

18. The DWMHA UM Appeal Coordinator, designated Crisis Service Vendor staff person or designated MCPNstaff person documents the date the Notice of Appeal Decision for the Uninsured or Under Insured form(if applicable) is mailed in their tracking log and their electronic system.

PROCEDURE MONITORING & STEPS Who monitors this procedure: DWMHA UM Appeal Coordinator


Frequency of monitoring: Monthly

Reporting provided to: Director of UM

Regulatory Requirement(s): NCQA-UM 8 &9 and the Medicaid State Contract, October 1, 2016

MONITORING STEPS 1. The designated Crisis Service Vendor staff person and designated MCPN staff person must forward via

email their completed standardized tracking log to the DWMHA UM Appeals Coordinator by the 10th of

each month for compliance monitoring. In addition, a copy of the appeal case is forwarded to the

DWMHA UM Appeals Coordinator for purpose of performing an audit to ensure the case was processed

in accordance with the UM Provider local and alternative dispute resolution Policy and Procedures.

2. Appeal and denial audit tools are used to audit 100% of the cases.

3. The results of the monthly audits will be reported to the DWMHA UM Director as well as to the

designated Crisis Service Vendor or designated MCPN staff member.

4. Quarterly results of the audits will be presented to the Utilization Management Committee (UMC).

5. For any cases scoring less than 85%, one on one review of the case will be done by the DWMHA UM

Appeal Coordinator to either the designated Crisis Service Vendor or MCPN staff member.

6. If any cases score less than 85% on the audit for three (3) consecutive months, Crisis Service Vendor or

MCPN will be placed on a corrective action plan (CAP).

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Detroit Wayne Mental Health Authority (DWMHA)707 West Milwaukee Street

Detroit, Michigan 48202

ADVANCE NOTICE OF ACTIONUninsured or Under Insured Members/Enrollees

Date

Name Address City, State, Zip Code

Re: Member/Enrollee’s Name: _____________________________________________________________

MHWIN ID #:

The reason for this action is _______________________________________________________________

Following a review of the mental health services and supports you are currently receiving, it has been determined

that the following service(s) shall be reduced, terminated, suspended or denied.

Service(s) Effective Date(s)

The reason for this action is

For a provider, if you do not agree with this action, you may request a Local Dispute Resolution, either orally or in writing, within 45 calendar days of the date of this notice by contacting Detroit Wayne Mental Health Authority (DWMHA) at (313)-344-9099 or TTY (800)-630-10444 and speaking with the Utilization Management Department.

For an enrollee/member, if you do not agree with this action, you may request a Local Dispute Resolution, either orally or in writing, within 30 calendar days of the date of this notice by contacting Detroit Wayne Mental Health Authority (DWMHA) at (313)-344-9099 or TTY (800)-630-1044 and speaking with the Customer Service Department.

You can send us any evidence you want us to review, such as medical records, doctors’ letters, or other information that explains why you need the item or service. Call your doctor for this information. Our address is707 West Milwaukee Street, Detroit, Michigan 48202 Attention: Customer Service.

You can also ask to see the medical records and other documents we used to make our decision before orduring the appeal. At no cost to you, you can also ask for a copy of the guidelines we used to make ourdecision.

of 2Revised 5.10.17

EXPEDITED LOCAL DISPUTE RESOLUTIONYou have a right to an expedited (faster) local dispute resolution if waiting for the standard time would seriously jeopardize your life, health and/or your ability to attain, maintain, or regain maximum function. To request an expedited local appeal, contact the Customer Service Department at Detroit Wayne Mental Health Authority (DWMHA) at the numbers listed above. You can also choose to have someone help you with your Local Dispute Resolution. You can also choose to have someone represent you during the Local Dispute Resolution process. If you want someone else to act for you, call us at: (313)-344-9099 to learn how to name your representative. TTY users call (800)- 630-1044. Both you and the person you want to act for you must sign and date a statement confirming this is what you want. You’ll need to mail or fax (313)-833-2217 this statement to the DWMHA Customer Service Department.

Upon receiving a local dispute resolution review request from a provider, we will review your request, make adecision and provide you with a written explanation of the decision within 20 calendar days for a standardrequest and within 72 hours for an expedited request.

Upon receiving a local dispute resolution review request from an enrollee/member, we will review your request,make a decision and provide you with a written explanation of the decision within 10 calendar days for astandard request and within 72 hours for an expedited request.

For an enrollee/member, if you do not agree with the outcome of the Local Dispute Resolution action, you mayrequest an Alternative Dispute Resolution in writing to The Michigan Department of Health and Human Services(MDHHS) at:

DEPARTMENT OF HEALTH AND HUMAN SERVICESDIVISION OF PROGRAM DEVELOPMENT, CONSULTATION AND CONTRACTS

BUREAU OF COMMUNITY MENTAL HEALTH SERVICESATTENTION: REQUEST FOR MDHHS LEVEL DISPUTE RESOLUTION

LEWIS CASS BUILDING-6TH FLOORLANSING, MICHIGAN 48193

_______________________________Decision Maker’s Signature

__________Date

________________________________Decision Maker (Printed Name) with Credentials/Job Title

Enclosures: Local Dispute Resolution Request Formcc: Member/Enrollee and/or Authorized Representative, and Service Provider

of 2Revised 5.10.17

Detroit Wayne Mental Health Authority (DWMHA)707 West Milwaulkee Street


ADEQUATE NOTICE OF ACTIONUninsured or Under Insured Members/Enrollees

Date

Name AddressCity, State, Zip Code

Re: Member/Enrollee’s Name: _____________________________________________________________MHWIN ID #:____________________________________________________________________________

Following a review of the mental health services and supports for which you have applied or are receiving, it has

been determined that the following service(s) are being reduced, terminated, suspended or denied.


The reason for this action is ___________________________________________________________

The legal basis for this decision is 42 CFR 440.230(d) and the Medicaid Provider Manual Behavioral Health andIntellectual and Developmental Disability Supports and Services Chapter.

If you do not agree with this action, you may request a Local Appeal, either orally or in writing, within 45 calendar days of the date of this notice by contacting Detroit Wayne Mental Health Authority (DWMHA) at (313)-344-9099 or TTY (800)-630-1044. For an enrollee/member appeal, ask for the DWMHA Customer Service Department and for a provider/utilization management appeal, ask for the DWMHA Utilization Management Department.You can send us any evidence you want us to review, such as medical records, doctors’ letters, or otherinformation that explains why you need the item or service. Call your doctor for this information. Our address is707 West Milwaukee Street, Detroit, Michigan 48202 Attention: Customer Service.

You can ask to see the medical records and other documents we used to make our decision before or during theappeal. At no cost to you, you can also ask for a copy of the guidelines we used to make our decision.

EXPEDITED LOCAL DISPUTE RESOLUTIONYou have a right to an expedited (faster) local dispute resolution if waiting for the standard time would seriously jeopardize your life, health and/or your ability to attain, maintain, or regain maximum function. To request an expedited local appeal, contact the Customer Service Department at Detroit Wayne Mental Health Authority(DWMHA) at the numbers listed above. You can also choose to have someone help you with your Local Dispute Resolution. You can also choose to have someone represent you during the Local Dispute Resolution process. If you want someone else to act for you, call us at: (313)-344-9099 to learn how to name your representative. TTY users call (800)- 630-1044. Both you and the person you want to act for you must sign and date a statement confirming this is what you want. You’ll need to mail or fax (313)-833-2217 this statement to the DWMHA Customer Service Department.

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Upon receiving an appeal request, we will review your request, make a decision and provide you with a writtenexplanation of the decision within 30 calendar days for a standard appeal request and within 72 hours for anexpedited appeal request.

For an enrollee/member, if you do not agree with the outcome of the Local Dispute Resolution action, you mayrequest an Alternative Dispute Resolution in writing to The Michigan Department of Health and Human Services(MDHHS) at:

DEPARTMENT OF HEALTH AND HUMAN SERVICESDIVISION OF PROGRAM DEVELOPMENT, CONSULTATION AND CONTRACTS

BUREAU OF COMMUNITY MENTAL HEALTH SERVICESATTENTION: REQUEST FOR MDHHS LEVEL DISPUTE RESOLUTION

LEWIS CASS BUILDING-6TH FLOORLANSING, MICHIGAN 48193


__________ Date


Enclosures: Local Dispute Resolution Formcc: Member/Enrollee and/or Authorized Representative, and Service Provider



ACKNOWLEDGEMENT OF PROVIDER LOCAL DISPUTE RESOLUTION REQUEST FOR UNINSURED OR UNDER INSURED ENROLLEE/MEMBER

Date

Provider Name AddressCity, State, Zip Code

Re: Enrollee/Member’s Name:MHWIN ID No: __________________________________________________

Dear __________________:

We received your (First Level or Second Level Local Dispute Resolution request) on <insert date>:

A resolution will be rendered within 72 hours of receipt of the expedited pre-service 1st level appeal request.

A resolution will be rendered within 20 calendar days of receipt of the standard pre-service 1st level appeal request.

A resolution will be rendered within 30 calendar days of receipt of the post-service (retrospective) 1st level appeal request.

A resolution will be rendered within 20 calendar days of receipt of the pre-service 1st level appeal request as your request for an expedited resolution has been DENIED.

A resolution will be rendered within 72 hours of receipt of the standard pre-service 2nd level appeal request.

A resolution will be rendered within 10 calendar days of receipt of the standard pre-service 2nd level appeal request.

A resolution will be rendered within 15 calendar days of receipt of the post-service (retrospective) 2nd level appeal request.

A resolution will be rendered within 10 calendar days of receipt of the pre-service 2nd level appeal request as your request for an expedited resolution has been DENIED.

Sincerely,

<Name of Responsible Party> <Title>

Revised 5.10.17

Department of Health and Human Services Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0950

Appointment of Representative

Name of Party Medicare or National Provider Identifier Number

Section 1: Appointment of Representative To be completed by the party seeking representation (i.e., the Medicare beneficiary, the provider or the supplier): I appoint this individual, to act as my representative in connection with my claim or asserted right under title XVIII of the Social Security Act (the “Act”) and related provisions of title XI of the Act. I authorize this individual to make any request; to present or to elicit evidence; to obtain appeals information; and to receive any notice in connection with my appeal, wholly in my stead. I understand that personal medical information related to my appeal may be disclosed to the representative indicated below. Signature of Party Seeking Representation

Street Address Phone Number (with Area Code)

City State Zip Code

Date

Section 2: Acceptance of Appointment To be completed by the representative: I, , hereby accept the above appointment. I certify that I have not been disqualified, suspended, or prohibited from practice before the department of Health and Human Services; that I am not, as a current or former employee of the United States, disqualified from acting as the party’s representative; and that I recognize that any fee may be subject to review and approval by the Secretary. I am a / an

(Professional status or relationship to the party, e.g. attorney, relative, etc.) Signature of Representative Date

Street Address Phone Number (with Area Code)

City State Zip Code

Section 3: Waiver of Fee for Representation Instructions: This section must be completed if the representative is required to, or chooses to waive their fee for representation. (Note that providers or suppliers that are representing a beneficiary and furnished the items or services may not charge a fee for representation and must complete this section.) I waive my right to charge and collect a fee for representing before the Secretary of the Department of Health and Human Services. Signature Date

Section 4: Waiver of Payment for Items or Services at Issue Instructions: Providers or suppliers serving as a representative for a beneficiary to whom they provided items or services must complete this section if the appeal involves a question of liability under section 1879(a)(2) of the Act. (Section 1879(a)(2) generally addresses whether a provider/supplier or beneficiary did not know, or could not reasonably be expected to know, that the items or services at issue would not be covered by Medicare.) I waive my right to collect payment from the beneficiary for the items or services at issue in this appeal if a determination of liability under §1879(a)(2) of the Act is at issue. Signature Date

Form CMS-1696 (Rev 06/12)

Charging of Fees for Representing Beneficiaries Before the Secretary of the Department of Health and Human Services An attorney, or other representative for a beneficiary, who wishes to charge a fee for services rendered in connection with an appeal before the Secretary of the Department of Health and Human Services (DHHS) (i.e., an Administrative Law Judge (ALJ) hearing, Medicare Appeals Council review, or a proceeding before an ALJ or the Medicare Appeals Council as a result of a remand from federal district court) is required to obtain approval of the fee in accordance with 42 CFR §405.910(f).The form, “Petition to Obtain Representative Fee” elicits the information required for a fee petition. It should be completed by the representative and filed with the request for ALJ hearing or request for Medicare Appeals Council review. Approval of a representative’s fee is not required if: (1) the appellant being represented is a provider or supplier; (2) the fee is for services rendered in an official capacity such as that of legal guardian, committee, or similar court appointed representative and the court has approved the fee in question; (3) the fee is for representation of a beneficiary in a proceeding in federal district court; or (4) the fee is for representation of a beneficiary in a redetermination or reconsideration. If the representative wishes to waive a fee, he or she may do so. Section III on the front of this form can be used for that purpose. In some instances, as indicated on the form, the fee must be waived for representation

Authorization of Fee The requirement for the approval of fees ensures that a representative will receive fair value for the services performed before DHHS on behalf of a beneficiary, and provides the beneficiary with a measure of security that the fees are determined to be reasonable. In approving a requested fee, the ALJ or Medicare Appeals Council will consider the nature and type of services rendered, the complexity of the case, the level of skill and competence required in rendition of the services, the amount of time spent on the case, the results achieved, the level of administrative review to which the representative carried the appeal and the amount of the fee requested by the representative.

Conflict of Interest Sections 203, 205 and 207 of title XVIII of the United States Code make it a criminal offense for certain officers, employees and former officers and employees of the United States to render certain services in matters affecting the Government or to aid or assist in the prosecution of claims against the United States. Individuals with a conflict of interest are excluded from being representatives of beneficiaries before DHHS.

Where to Send This Form Send this form to the same location where you are sending (or have already sent): (1) your appeal if you are filing an appeal, (2) grievance if you are filing a grievance, or (3) initial determination or decision if you are requesting an initial determination or decision.

If additional help is needed, contact your Medicare plan or 1-800-MEDICARE (1-800-633-4227).

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0950. The time required to prepare and distribute this collection is 15 minutes per notice, including the time to select the preprinted form, complete it and deliver it to the beneficiary. If you have comments concerning the accuracy of the time estimates or suggestions for improving this form, please write to CMS, PRA Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

Form CMS-1696 (Rev 06/12)

Detroit-Wayne Mental Health Authority (DWMHA)707 west Milwaulkee Street


REQUEST FOR ADDITIONAL INFORMATION

Date

Provider Name AddressCity, State, Zip Code

RE: Enrollee/Member’s Name:________________________________________________MHWIN ID No:____________________________________________________________

Dear ___________________:

We received your (Insert either First Level Appeal request or Second Level Appeal request) on <insert date>.

However, in order to make a fair and informed determination, we are requesting the following information be sent within five (5) calendar days:o Psychiatric Evaluationo Nursing Assessmento Social Work Assessmento Substance Abuse Assessmento Master Treatment Plano Attending Physician Progress Noteso Clinical Group Progress Noteso Clinical Individual Progress Noteso Medication Administration Recordo Vital Signs and Meals Flow Charto Discharge Summaryo Other _________________________________________________________

Because of our request for additional information, we are extending the decision date by fourteen (14) calendar days. If you have any questions please contact DWMHA at 313-344-9099. Providers ask for the Utilization Department and enrollees/members ask for the Customer Service Department.

Sincerely,

<Name of Responsible Party><Title>

Revised 5.10.17

ENROLLEE / MEMBER AGREEMENT FOR ADDITIONAL INFORMATION REQUEST

Date

Enrollee/Member Name AddressCity, State, Zip Code

Re: Enrollee/Member’s Name:_________________________________________________________MHWIN ID No: ____________________________________________________________________

Dear ____________________:

We received the request for an (Insert either First Level Appeal request or Second Level Appeal request) on <insert date> from your provider. However, in order to make a fair and informed determination, we requested the following information be sent within five (5) calendar days from your provider:

Psychiatric Evaluation

Nursing Assessment

Social Work Assessment

Attending Physician Progress Notes

Clinical Group Progress Notes

Clinical Individual Progress Notes

Medication Administration Record

Vital signs and Meal Flow Chart

Discharge Summary

Other______________________________________________________________

Because of our request for additional information, we are extending the decision date by fourteen (14) calendar days. If you or your representative are not in agreement with this extension, you or your representative can verbally request an expedited grievance with DWMHA’s Customer Service Department at (313)- 344-9099 or (888)-490-9698 or TTY (800)-630-1044 or in writing at 707 West Milwaukee, Detroit Michigan 48202.

Sincerely,

<Name of Responsitle Person>

<Title>

Revised 5.10.17

UNINSURED OR UNDER INSURED LOCAL DISPUTE RESOLUTION REQUEST FORM

SECTION 1 – Local Dispute Resolution Request□ Oral Request Date : _______________ □ Written Request Date: ______________

Local Dispute Resolution Request for Providers: □ Standard Resolution (30 days) or □ ExpeditedResolution (3 days)

Local Dispute Resolution Request for Enrollees/Members: □ Standard Resolution (10 days) or

□ Expedited Resolution (3 days)

Who is requesting Local Dispute Resolution: □ Enrollee/member □ Authorized Representative □ Provider

SECTION 2- Enrollee/member InformationEnrollee/Member’s Name Home phone no. Work or Cell phone no.

Address (No. & Street, Apt. #, etc.) City State ZipCode

Date of Birth MHWIN ID No. Member Signature Date Signed

SECTION 3 – Provider Information

Name of Provider: Office phone no. Date of Notice

Address (No. & Street, Apt. #, etc.) City State Zip Code

Provider Contact Person: Provider Signature Date Signed

SECTION 4- Have you chosen someone to assist or represent you with this request?□ YES (please fill in information below) □ NO

Name of Authorized Representative: Home phone no. Work or Cell phone no.

Address (No. & Street, Apt. #, etc.) City State Zip Code

Representative Signature Date Signed

SECTION 5- Reason for Local Dispute ResolutionThe following are my reason(s) for requesting a local dispute resolution. Use Additional Sheets if Needed.

I would like an opportunity to look at case/medical file or any records that will be considered during the appeal? □ Yes □ NO Date: _______Time: ___________ Staff Name: _____________________________

I would like an opportunity to present information for review/ consideration during the appeal process? □ Yes □ NO Date: ______Time: ___________ Staff Name: ____________________________

Form completed by: ____________________________ Date completed: ____________________

INSTRUCTIONS FOR COMPLETION

SECTION 1 – Local Dispute Resolution RequestCheck off if the request is filled out by enrollee/member, provider or authorized representative or if the form is being completed due to an oral request.

SECTION 2 – Enrollee/Member InformationEnter information about the enrollee/member who is the requesting the local dispute resolution, including the provider information.

SECTION 3- Provider InformationEnter information about the provider who is the requesting the local dispute resolution, including the provider information.

SECTION 4– Have you chosen someone to assist or represent you with this request?Enter information that identifies the authorized representative – the enrollee/member may choose someone to represent them or assist with the appeal process.

SECTION 5- Reason for Local Dispute Resolution Request

This form may be completed by the enrollee/member, provider, authorized representative, or any person including DWMHA, MCPN or staff person who is assisting the Uninsured or Under Insured enrollee/member with the Local Dispute Resolution process.

Revised 3.1.17

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Notice of Appeal Decision

for the Uninsured or Under Insured Enrollee/Member Important: This is notice explains your right to appeal our decision. Read this notice carefully. If you need help, you can call one of the numbers listed on the last page under “Get help & more information.”

Mailing Date: Enrollee/Member MHWIN Number:

Enrollee/Member Name:

Provider Name:

This Notice is in response to the internal appeal request that we received on (insert appeal date)

Type of Service Subject to Notice:

_________________________________________________________________________________________

_________________________________________________________________________________________

Your appeal was denied

Your appeal was thoroughly considered. This is to inform you that we [denied or partially denied] your appeal for the service/item listed below:

Why did we deny your appeal?

We [denied or partially denied] your appeal for the service/item listed above because: [Include citations withdescriptions that are understandable to the member of applicable State and Federal rule, law, and regulation

that support the action. You may also include Evidence of Coverage/Member Handbook provisions as well as

Plan policies/procedures or assessment tools used to support the decision.]

You should share a copy of this decision with your doctor so you and your doctor can discuss next steps. If your doctor requested coverage on your behalf, we have sent a copy of this decision to your doctor.

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If you do not agree with our decision, you have the right to appeal Providers have a right to request a Level 2 Appeal from Detroit Wayne Mental Health Authority. The request can be vrebal by contacting 313-344-9099 and ask to speak with the Utilization Management Department or the request can be in writing to:

DWMHA-Utilization Management

Dept. 707 West Milwaukee StreetDetroit, Michigan 48202

How to request an Alternative Dispute Resolution with the Michigan

Department of Health and Human Services (MDHHS): For an enrollee/member, if you do not agree with the outcome of the Local Dispute Resolution action, you may request an Alternative Dispute Resolution in writing to The Michigan Department of Health and Human Services (MDHHS) at:

Department of Health and Human Services

Division of Program Development, Consultation and Contracts

Bureau of Community Mental Health Services

Attention: Request for MDHHS Level Dispute Resolution

Lewis Cass Building-6TH FLOOR

Lansing, Michigan 48193

Access to Documents You and/or your authorized representative are entitled to reasonable access to and a free copy of all documents relevant to your appeal any time before or during the appeal. You must submit the request in writing to:

Detroit Wayne Mental Health Authority (DWMHA)

707 W. Milwaukee Street

Detroit MI, 48202

Get help & more information

Detroit Wayne Mental Health Authority (DWMHA): If you need help or additional information aboutour decision and the appeal process, call (313)-344-9099 or (888)-490-9698, TTY (800)- 630-1044,Monday-Friday, 8:00am to 4:30pm. For an enrollee/member appeal, ask for the DWMHA CustomerService Department and for a provider/utilization management appeal, ask for the DWMHA UtilizationManagement Department. You can also visit our website at www.dwmha.com

DWMHA’s 24 hour Crisis Helpline Toll Free: 1-800-241-4949, TTY: 711__________________________________________________________________________________ You can get this information for free in other languages or in other formats, such as large print, Braille or audio by calling toll free 1-888-490-9698 (TTY 1-800-630-1044) during normal business hours, Monday through Friday, 8:00am to 4:30pm.

Usted puede hablar con una persona para obtener esta informacion gratuitamente en espanol o en varios formatos, tal como en letras grandes, idioma Braille o en forma hablada, llamando al 888-490-9698 (TTY: 1-800-630-1044) durante las horas de trabajo: 8:00 am a 4:30 pm de Lunes a Viernes. La llamadaesgratuita.

الحصول على هذه المعلومات باللغة العربية أو بتنسيقات مختلفة مثل طريقة باريل، بخط كبير أو صوتيا عن طريق اإلتصال برقم الهاتف يمكنك مساءأ 4:30 صباحاأ إلى الساعة 8:00 .خالل مواعيد العمل الرسمية من اإلثنين إلي الجمعة من الساعة1-888-490-9698المجاني

CC: Provider, Enrollee/Member

http://www.dwmha.com/

tel:(800)%20490-9698

tel:(800)%20630-1044

tel:(800)%20490-9698

tel:(800)%20630-1044

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ADMINISTRATIVE APPEAL DETERMINATION FORM

Date

Name AddressCity, State, Zip Code

Re: Member/Enrollee’s Name:

Medicaid /Healthy Michigan/MI Health Link/No Insurance (Circle all that apply) ID #:

MHWIN ID #:

We have received your request for an appeal. Following the administrative appeal review of services and supportsfor which you have requested, it has been determined that that the following service(s) are being:

Authorization Request #:


The reason for this action is:

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Member: If you receive a bill, please contact Detroit Wayne Mental Health Authority (DWMHA) at (313)-344-9099 or TTY (800)-630-1044. Your services will not be denied, reduced, suspended or terminated as a result of an Administrative denial.

Provider: This is the Final Level of Appeal. If you would like to speak with the professional who rendered thedetermination regarding the decision, please call the UM Department.


__________Date


cc: Service Provider & Member

Revised 8/3/2017