Provider Reconsideration Guide

Transcription

1 Provider Reconsideration Guide Prior Authorization Request (PAR) Denials eqhealth Solutions offers providers an opportunity to request a reconsideration review when an adverse determination is received. A request for reconsideration is applicable for a) full or partial medical necessity denial determinations, b) Lack of Information (LOI) denials, and c) other technical denials. Medical Necessity Full Denial/Partial Denial When a full or partial medical necessity denial is issued from eqhealth Solutions Physician Reviewer, the following opportunities are available: If the ordering physician would like to participate, a Peer-to-Peer (P2P) discussion with an eqhealth physician reviewer may be requested within 5 calendar days of the full/partial denial decision necessity denial. This may afford the opportunity to prevent a request for reconsideration. The Peer-to-Peer process is under Provider Resources at OR A provider, attending, or ordering physician has the opportunity to request a reconsideration review within ten (10) calendar days of the full/partial denial decision. eqhealth performs two types of medical necessity reconsiderations: o Expedited Reconsideration for a review that was marked as Expedited/Urgent by the provider when originally submitted. o Standard All other adverse determinations Follow the instructions below to request a medical necessity reconsideration via eqsuite : Select Letters on the menu bar, search by ClientID and click View Letter o Click View on the OP Outcome-Denial row to see the clinical rationale for the denial and share with the treating physician to prepare your response for reconsideration.

2 Note: The letter date is considered the date of denial Select Respond to Denial on the menu bar to submit your request for reconsideration. Note: Do not begin this process until ready to submit all necessary information/documents. o Search by Review ID and click Open Review NOTE: This option is available for 10 calendar days from the date of the denial. Untimely requests may be granted after 10 days by faxing the request.

3 Select the RECON tab Click I do not agree to request a reconsideration review. Type in justification of medical necessity to be considered with your request Check the box if you are attaching supporting documents. It is advisable to include additional information with the reconsideration request, based on reason for denial. Click Submit Recon Info. Next, click Link Attachments and you will be prompted to print attachment coversheet or upload attachment images. Technical Denial Lack of Information Prior Authorization Requests (PARs) submitted without the required documentation may result in a Lack of Information (LOI) denial after 4 business days, when: a) The PAR is missing the appropriate attachments for that service type. These PARs will show a Record Status of Awaiting Required Attachments b) The PAR is pended because it requires additional information than what was already submitted in order to make a PAR determination. When a technical denial is issued from eqhealth Solutions, please obtain the denial reason from the PAR letter on the Colorado Medicaid Web portal or by contacting the ColoradoPAR customer service line. After receiving the technical denial reason, the following methods are available: Best method: If the requestor has the required documents and/or clinical information needed for medical necessity review, the most efficient and quickest method is: o Submit a new request to eqhealth Solutions with all necessary information.

4 Alternative Method: If the requestor needs to follow up with the provider, attending or ordering physician to get the required documents and/or clinical information, this is a viable method to respond to a LOI denial: o If the PAR was not resubmitted, a provider, attending, or ordering physician may request a reconsideration review within ten (10) calendar days of the LOI (technical) denial. Submit request to eqhealth Solutions with all necessary information. Technical Denial - Other Prior Authorization Requests (PARs) submitted to eqhealth Solutions must align with Colorado Medicaid policies. If the PAR request is not consistent with coverage or benefit limits or other requirements, a technical denial is issued based on a policy decision. When a technical denial is issued from eqhealth Solutions, please obtain the denial reason from the PAR letter on the Colorado Medicaid Web portal or by contacting the ColoradoPAR customer service line. After receiving the technical denial reason, the following methods are available: Best method: If the requestor has knowledge and information to support the disagreement of the technical denial reason, the most efficient and quickest method is: o Submit a new request to eqhealth Solutions with all necessary information. Include clarifying information in the summary to explain why it should not receive a technical denial. Alternative Method: If the requestor has knowledge and information to support the disagreement of the technical denial reason, this method may also be used: o If the PAR was not resubmitted, a provider, attending, or ordering physician may request a reconsideration review within ten (10) calendar days of the denial date and include clarifying information to explain why it should not receive technical denial. **NOTE: Do not use both methods to respond to the same LOI or technical denial**

5 Submitting a Request for Reconsideration eqhealth Solutions accepts requests for reconsideration via eqsuite, fax, phone or USPS mail. The methods, available by denial type are shown below: Request for Reconsideration Review Methods Type of Denial eqsuite Fax Phone Mail Medical Necessity Full/Partial Lack of Information (LOI) Technical Denial To submit via mail, fax, or phone, please use the approved Reconsideration Request Form at Provider Resources Reconsideration Process If submitted after 10 business days, the reason for late request must be included or the request will be canceled. Please visit the Contact Information section on our homepage at for current ColoradoPAR customer service line, fax and mailing address information.