Authorization
Appeals
Utilization Management (Authorization) Appeals
Nationally recognized criteria for medical necessity (InterQual) and the Medicaid Coverage and Limitations Handbooks are used to evaluate requests for medical appropriateness/necessity and benefits. If the request meets all the criteria, it will be assigned an authorization number by MED3000.
If InterQual criteria are not met or the requested service exceeds the Medicaid covered allowable, is not a covered benefit, or is a request for an out-of-network provider/service, the request will be forwarded to the University of Florida ICS Medical Director for review. Only the ICS Medical Director is able to deny a request for authorization of services.
If the request for authorization for services is denied, a phone call will be made to the provider within one (1) business day of the decision, followed up by a letter to the provider, the member and the CMS Nurse Care Coordinator, explaining the reason for the denial. The letter will be signed by the Ped-I-Care Medical Director who made the decision.
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First
Level Appeal
The provider may submit a written appeal of this decision. An appeal must be submitted in writing within thirty (30) days of notification of the denial, or within three (3) business days to be considered for an expedited appeal. The appeal must be filed using the Authorization Denial Appeal Form. Mail completed appeal form to: Ped-I-Care Authorization Appeals Coordinator 1701 SW 16th Avenue, Building A, Gainesville, FL 32608, or fax it to 352-955-6518 The appeal will be reviewed by a Ped-I-Care Medical Director who was not involved in the initial decision. The provider will be notified within thirty (30) calendar days if the appeal is denied.
Second Level Appeal
Providers will be given the opportunity for a second level appeal, in which they will be able to present their request to a committee that includes experts in the relevant calendararea. They must request this appeal in writing within thirty (30) days of denial of the first appeal. The committee will notify the provider within thirty (30) calendar days of its decision.
Expedited Utilization Management Appeals
Expedited appeals must be requested within three (3) business days from the denial and meet the following criteria:
1. Ped-I-Care must have made a determination that coverage will not be provided for health care services because such services do not meet Ped-I-Care's requirements for medical necessity, appropriateness, health care setting, level of care, or effectiveness; and,
2. The member's life or health, or the member's ability to regain optimum function, would be seriously jeopardized or would subject the member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the request, by waiting for Ped-I-Care to review its denial through the standard appeals process time frames; and,
3. The provider refuses to provide the service(s) until coverage or payment is guaranteed by Ped-I-Care or the member; and,
4. The Ped-I-Care Medical Director confirms the request meets the criteria for expedited review.
The following time frames apply to expedited appeals:
◊ The initial appeal must be filed within three (3) business days
◊ The provider will be notified by telephone within three (3) business days of the response to the appeal and followed up with a written response
◊ A second level expedited appeal must be filed within three (3) business days from the first level denial
◊ A meeting or a conference call will be scheduled within ten (10) business days to address the next level of appeal
◊ The provider will be notified by telephone within three (3) business days of the decision on the second level appeal.
◊ All of these time frames may be lengthened if both parties agree.
If the patient's condition mandates a more rapid response to the
appeal request than these guidelines allow, Ped-I-Care will do everything
possible to expedite and hasten the process.
