Independent External Review of Health Care Decisions in Vermont

Department of Banking, Insurance, Securities Department of Banking, Insurance, Securities and Health Care Administrationand Health Care Administration

Legal Basis for independent external review of health care decisions in Vermont

8 V.S.A. §4089f Regulation H-99-1

Division of Health Care AdministrationDivision of Health Care Administration

Features of independent external review of health care decisions in Vermont: insured has the opportunity to obtain

external review of insurer’s decision by impartial medical expert (Division of Health Care Administration contracts with independent review organizations)

all final denial letters from insurers to include notice of possible right to appeal to Division of Health Care Administration

records of and materials prepared for reviews are exempt from public disclosure under 1 V.S.A. § 316

cost to insured: $25.00 (may be waived for financial hardship); insurer pays other costs of review

representation not necessary, although insured may be represented if desired

Features. . .

relatively quick decision

insurer bound by decision if denial overturned

insured may pursue other remedies

Features. . .

Generally applies to health benefit plans, whether:

managed care

HMO

indemnity

PPO

This process not available for:

decisions relating to mental health and substance abuse treatment decisions (see 8 V.S.A. §4089a and Regulation 95-2, Department of Banking, Insurance, Securities and Health Care Administration

decisions relating to health care services covered under a Medicaid program (existing fair hearing process)

decisions relating to health care services covered under a Medicare program (existing Medicare appeals process)

decisions relating to services provided by the Vermont Department of Corrections (existing Corrections appeals process)

An “appealable decision” under H-99-1 is a decision by a health insurer to deny, reduce or terminate health care coverage or to deny payment where:

the health care service would cost the insurer at least $100.00;

the insured has exhausted all internal appeal rights (see § 10.203(D) of Rule 10 for managed care plans, § 4 and § 5 of H-99-1 for health plans not subject to Rule 10)

Grounds for review:

1. The health care service is a covered benefit that the health insurer has determined to be not medically necessary.

1. help restore or maintain the member’s health; or

2. prevent deterioration of or palliate the member’s condition; or

3. prevent the reasonably likely onset of a health problem or detect an incipient problem.

2. A limitation is placed on the selection of a health care provider that is claimed by the insured to be inconsistent with limits imposed by the health benefit plan and any applicable laws and regulations.

Grounds for review:

Grounds for review:

3. The health care treatment has been determined to be experimental or investigational or an off-label use of a drug.

Grounds for review:

4. The health care service involves a medically-based decision that a condition is preexisting.

Other threshold requirements:

individual is or was an insured of the health insurer;

application made within 90 days from receipt of the written determination of the final level of insurer’s internal appeals process (oral request timely if confirmed in writing within 10 days);

the service that is the subject of the appeal reasonably appears to be a covered service under the benefits provided by contract to the insured

Application procedure: Individual (or representative) contacts

Division of Health Care Administration for information, application and assistance with application if needed (24 hour/7 day availability for emergencies)

Applicant returns completed application, copy of final denial letter and filing fee ($25.00) or request for waiver of fee due to financial hardship to Division of Health Care Administration

application is reviewed by Division of Health Care Administration to determine if complete, required release and designation of representative (if applicable) signed

application, denial letter, contract and any additional information from insurer regarding contractual issues reviewed to determine if request meets “appealable decision” criteria

Time frames:Requests for routine review:

Division must accept request or request additional information within 5 business days of receipt.

If accepted, Division notifies parties of their opportunity to submit information and supporting documentation for consideration by independent review organization (within 10 days of receipt of notice).

Requests for routine review:

Division exchanges parties’ submissions; they may file responsive information within 3 days.

All submissions by parties sent by Division to independent review organization.

If requested at time of application, insured and provider may have telephone conference with reviewer and clinical representative of insurer to review and discuss clinical evidence in appeal.

Requests for routine review:

Independent review organization submits decision based on objective clinical evidence to Division as soon as possible consistent with the medical exigencies of the case but in not more than 30 days.

Division reviews to ensure decision does not change the terms of coverage under the contract and issues to parties.

Time frames:Requests for expedited review:

Division determines appealability immediately and notifies parties of opportunity to submit information and documentation.

Parties have 48 hours to submit information and documentation; exchange and response and telephone conference conducted expeditiously.

Requests for expedited review:

Independent review organization submits decision based on objective clinical evidence to Division as soon as possible consistent with the medical exigencies of the case but in not more than 5 days.

Division reviews to ensure decision does not change the terms of coverage under the contract and issues to parties

Process For Reviewing Mental Health Care And Substance Abuse Treatment

Health Care Decisions In Vermont:Independent Panel of

Mental Health Care Providers

Panel reviews decisions of mental health utilization review agents re: mental health care and substance abuse treatment.

Legal basis: 8 V.S.A. § 4089a Regulation 95-2

Features of Independent Panel Review that Differ from External Review:

Insured has opportunity to obtain external review of review agent’s medical necessity decision by impartial panel of Vermont mental health and substance abuse care providers

Panel members include: psychiatrist, psychologist, mental health social worker, psychiatric nurse, mental health counselor and drug and alcohol counselor

Review agent must inform insured of right to panel appeal if first level appeal is denied

No application fee No threshold cost of service requirement Time frames differ slightly Process includes hearing before Panel