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PAM Section 5: Utilization Management

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Overview

The purpose of Mount Carmel MediGold Health Plan’s Utilization Management Program is to ensure the delivery of medically necessary, optimally achievable, quality care through appropriate utilization of resources in a cost effective and timely manner to all members. To ensure this level is achieved and/or surpassed, programs are consistently and systematically monitored and evaluated. 

Utilization Management is performed to ensure an effective and efficient medical and behavioral health care delivery system. It is designed to evaluate the cost and quality of medical services provided by participating physicians, hospitals and other ancillary providers.

The goal of utilization management is to assure appropriate utilization and to achieve the following objectives for all members to:

  • Assure effective and efficient utilization of facilities and services through an ongoing monitoring and educational program. The program is designed to identify patterns of utilization, such as overutilization, underutilization and inefficient scheduling of resources.
  • Assure fair and consistent Utilization Management decision-making.
  • Educate medical providers and other health care professionals on appropriate and cost-effective use of health care resources. Mount Carmel MediGold Health Plan works cooperatively with its participating providers to assure appropriate management of all aspects of the members’ health care.
  • Continually improve the quality of care and resource allocation within the organization.
  • Evaluate advancing medical technologies to determine the level of coverage provided to members.

Medical Necessity

The Utilization Management process will assess, direct, and efficiently navigate health care resources in a cost-effective manner for our members, while maintaining high-quality care. This process is accomplished through comprehensive interdisciplinary utilization and case management programs.

Mount Carmel MediGold Health Plan utilizes evidence-based medicine in its decision-making process. Utilization Management clinical review is applied in the determination of medically necessary services, ensuring that the criteria are applied consistently and fairly to all members. Criteria is reviewed and updated on an annual basis/as needed and is available to members and providers on our website.   

Resources utilized by Mount Carmel MediGold Health Plan in determining medically necessary services include, but are not limited to:

  • Medicare National and Local Coverage Determinations
  • MCG Health
  • National Comprehensive Cancer Network
  • Mount Carmel MediGold Health Plan policies and procedures
  • Medical literature

According to Plan policy, medical necessity is defined as those services determined by Mount Carmel MediGold Health Plan or its designated representative to be:

  • Preventive, diagnostic and/or therapeutic in nature
  • Specifically relates to the condition which is being treated/evaluated
  • Rendered in the least costly medically appropriate setting (e.g., inpatient, outpatient, office), based on the severity of illness and intensity of service required
  • Not solely for the member’s convenience or that of his or her physician
  • Supported by evidence-based medicine

The information needed will often include the following:

  • Patient name, member ID#, age, gender
  • Brief medical history
  • Diagnosis, co-morbidities, complications
  • Signs and symptoms
  • Progress of current treatment, including results of pertinent testing
  • Providers involved with care
  • Proposed services
  • Referring physician’s expectations
  • Psychosocial factors, home environment
  • For hospital admissions, 48 hours of clinical will be required to make a bed type determination

To view the criteria used by the plan to support a medical determination, visit our MCG portal.

Job Aid: Accessing criteria through the MCG portal

Please refer to the CMS website for the most current applicable National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/CMS Online Manual System/Transmittals. 

Submission Process

All requests will be reviewed by our Plan nurses and/or medical directors for determination.

Online: SNF, Hospital Admission Notification, Concurrent Review, and Oncology Services can submit their requests and upload supporting documentation using the Essette Provider Portal. There will be future services added to this submission process in the future. 

Access Essette Provider Portal

  • You will be asked a series of clinical questions
  • If MCG criterion are met, you will receive an approval along with authorization number for your records.
  • If you do not receive an approval upon submission, the request will be reviewed by our Plan nurses and medical directors for determination.
  • To obtain access to the Essette Provider Portal for Utilization Management, please call 1-800-240-3870.

Email: All services may submit an email request, along with appropriately completed Prior Authorization and/or Hospital Notification forms and clinical clinical supporting documentation to:

Fax: All services may submit a fax request, along with appropriately completed Prior Authorization and/or Hospital Notification forms and clinical supporting documentation to:

  • Hospital Admission and Concurrent Review: 1-833-263-4866
  • Skilled Nursing Admission and Concurrent Review: 1-833-263-4865
  • All other preservice requests: 1-833-263-4869
  • The request will be reviewed by our Plan nurses and medical directors for determination.
     

Phone: All services may submit an authorization request via phone. Please call 1-800-240-3870 and follow the prompts to load an authorization.

Turnaround Time for Pre-Service Organizational Determinations:

  • CMS allows up to 14 calendar days for standard organizational determinations. Mount Carmel MediGold Health Plan goal, if all information is submitted timely, is 3-5 calendar days.
  • CMS allows up to 72 hours for standard Part B drugs.
  • CMS allows up to 72 hours for expedited organizational determinations.
  • CMS allows up to 24 hours for expedited Part B drugs

Prior Authorization

Prior authorization is conducted to determine if the:

  • Requested treatment is a covered service.
  • Service is medically necessary and appropriate.
  • Service is performed by an appropriate provider.

Please refer to the Mount Carmel MediGold Health Plan Prior Authorization List for a complete list of procedure codes requiring prior authorization.

Prior Authorization Decision-Making Process

Services requiring prior authorization, for which prior authorization is not obtained, will not be covered by Mount Carmel MediGold Health Plan and may be subject to Mount Carmel MediGold Health Plan’s Remediation Policy. Requests for retrospective prior authorization will not be reviewed by the Plan.

Utilization patterns are monitored by Mount Carmel MediGold Health Plan and could lead to corrective action plan recommendations. Utilization data is included in physician profiling and may be considered at the time of re-credentialing.

When Mount Carmel MediGold Health Plan denies a prior authorization request for payment or services, we must issue a written Integrated Denial Notice (IDN) to an enrollee, an enrollee’s representative, or an enrollee’s physician. 
See the Provider Policies and Protocols section for more details.

Referrals

Referrals to out-of-network providers are authorized when a covered service is not available within the existing network of Mount Carmel MediGold Health Plan network providers. The referral must be requested by a network provider. Please attach referral to the prior authorization request form and include any documentation explaining the circumstances under which the member’s medically necessary need for covered services cannot be addressed by a Mount Carmel MediGold Health Plan network provider. Circumstances may include the existence of an ongoing treatment plan and/or a specific covered service that is not available from a Mount Carmel MediGold Health Plan network provider.

Hospital Notifications

Notifications are communications to Mount Carmel MediGold Health Plan regarding a member’s admission to or discharge from a hospital. Admission notification must be made within 2 business days and can be submitted by sending a completed Hospital Admission Notification Form via phone, fax, email, or portal. All submission options are above.

Notification of the members discharge date must be provided within 2 business days.

Concurrent Review

Mount Carmel MediGold Health Plan ensures the oversight and evaluation of members when admitted to hospitals, rehabilitation centers, and skilled nursing facilities (SNF). This oversight includes reviewing continued inpatient stays to ensure appropriate utilization of health care resources and to promote quality outcomes for members.

Mount Carmel MediGold Health Plan provides oversight for members receiving acute care services in facilities mentioned above to determine the initial and/or ongoing medical necessity, appropriate bed type, monitor length of stay stay (for certain settings), and to assist in facilitating a timely discharge.

Concurrent review is initiated as soon as Mount Carmel MediGold Health Plan’s utilization review nurses are notified of the admission. Subsequent reviews are based on the severity of the individual case, needs of the member, complexity, treatment plan and discharge planning activity. The authorization will occur concurrently based on guidelines for appropriateness of continued stay to:

  • Ensure that services are provided in a timely and efficient manner.
  • Make certain that established standards of quality care are met.
  • Implement timely and efficient transfer to a lower level of care when clinically indicated and appropriate.
  • Complete timely and effective discharge planning.
  • Identify referrals appropriate for case management (CM) or quality-of-care review. Identify cases appropriate for follow up by the CM/service coordinator.

These review criteria are utilized as a guideline. Decisions will take into account the member’s medical condition and co-morbidities. The review process is performed under the direction of the Mount Carmel MediGold Health Plan medical director.

The frequency of the review will be based on the provider type (hospital, rehab, SNF, etc.), as well as the clinical condition of the member. The frequency of the reviews for extension of initial determinations is based on the severity/complexity of the patient’s condition, necessary treatment and discharge planning activity, including possible placement in a different setting. Clinical information is requested to support the appropriateness of the admission, bed type determination, length of stay monitoring (for certain settings), treatment, and discharge plannings.

In cases where the hospital case manager and Mount Carmel MediGold Health Plan utilization review nurse do not agree on the decision:

Step 1: Hospital case manager sends additional clinical information to the Mount Carmel MediGold Health Plan utilization nurse to review. If a consensus cannot be reached at the nurse level, please move to step 2.

Step 2: Physician-to-physician (peer-to-peer) A physician involved with the patient’s care or physician advisor may request a Physician to Physician (peer-to-peer) discussion with a medical director by calling Utilization Management at 1-800-240-3870 within two business days of receiving the notice of determination. (If peer-to-peer is post-discharge, it is considered a request for review in step 3.)

Step 3: Request for Review of Inpatient Status. All post-discharge requests for review must be submitted to 1-833-263-4866 within 90 days from the date of discharge. This is a final review of your hospital determination and a decision will be provided within 7-10 business days of submission.

Readmission Process

A readmission is defined as an admission(s) to the same facility (based on Tax ID) within 30 days from discharge of the original admission.

When the Utilization Management Team determines that an Inpatient admission is a 30-day readmission to a facility, the health plan will use clinical judgment to determine if the care provided for the subsequent admission is for the same or closely related clinical condition as the prior condition or due to a potential complication related to a previous procedure/service/admission. The clinical team will also review for potential issues related to premature discharge or preventable with appropriate discharge planning.

The health plan has exclusions that the clinical team will review. The readmission exclusions are:

  • Oncology related services
  • Behavioral health related services
  • Transplant related services
  • Patients who have left against medical advice (AMA)

If the clinical team determines that the admissions are related to each other, the original admission will be linked to the second/subsequent admission(s) and combined as one authorization. If they are not deemed to be related or they meet an exclusion, a new authorization will be created. The UR Nurse will communicate the decision back to the servicing provider.

Urgent Care and Emergency Services

Urgently Needed Services means covered services that are needed by an enrollee who is temporarily absent from the plan's geographic area and that: 

  • Are required in order to prevent serious deterioration of the enrollee's health as a result of unforeseen injury or illness; and
  • Cannot be delayed until the enrollee returns to the plan's geographic area.

Emergency Services means covered inpatient or outpatient services that are furnished by an appropriate source other than the plan that:

  • Are needed immediately because of an injury or sudden illness; or
  • Are such that the time required to reach the plan's provider's or supplies (or alternatives authorized by the plan) would mean risk of permanent damage to the enrollee's health.

For urgent/emergency services:

Members are instructed to proceed to the nearest health care facility, whether or not that facility is a Mount Carmel MediGold Health Plan network provider. Members may contact their PCP if uncertain about their clinical condition or how to proceed. When calling the PCP, the member may be instructed to proceed to the nearest facility or to dial 911.

When a member presents to a network hospital emergency room for care and is admitted as an inpatient, the network hospital is required to notify Mount Carmel MediGold Health Plan within two business days.

For emergency services obtained from out-of- network providers, the member, the member’s family member or attending physician is responsible for notifying the member’s PCP within 48 hours.

Mount Carmel MediGold Health Plan reserves the right to transfer members whose condition is stable to network providers when the transfer can take place without harm to the member. Mount Carmel MediGold Health Plan also reserves the right to retrospectively review emergency room and urgent care records and may subsequently determine that the care was not a medically necessary emergency or an urgently needed service. This retrospective review may occur at the point of claims adjudication and/or upon UM audit of ER/urgent care services. Mount Carmel MediGold Health Plan will consider the perception of a ‘prudent layperson’ when reviewing urgently needed or emergency services.

Notifications to Members

CMS has developed standardized notices and forms for use by plans as described below:

Required Notification to Members for Observation Services: In compliance with the Federal Notice of Observation Treatment and Implication for Care Eligibility Act, contracted hospitals and critical access hospitals must deliver the Medicare Outpatient Observation Notice (MOON) to any member who receives observation services as an outpatient for more than 24 hours. The MOON is a standardized notice to a member informing them that they are an outpatient receiving observation services and not an inpatient of the hospital or critical access hospital and the implications of such status. The MOON must be delivered no later than 36 hours after observation services are initiated, or sooner upon release.

Integrated Denial Notice (IDN): Mount Carmel MediGold Health Plan is required to issue the Notice of Denial of Medical Coverage (or Payment), also known as the Integrated Denial Notice (IDN), upon denial, in whole or in part, of an enrollee’s request for coverage and upon discontinuation or reduction of a previously authorized course of treatment. The IDN consolidates Medicare Advantage coverage and payment denial notices. See the Policies and Provider Protocols section for more details.

Notice of Termination of Services for SNF, HHA, CORF: When Mount Carmel MediGold Health Plan has authorized coverage of services, Mount Carmel MediGold Health Plan is responsible for determining a member’s coverage termination date and providing a detailed explanation of termination of services as described in section 100 of the Medicare Managed Care Manual. Mount Carmel MediGold Health Plan will coordinate with skilled nursing facilities (SNFs), home health agencies (HHAs) and comprehensive outpatient rehabilitation facilities (CORFs) by providing a termination of services date as early in the day as possible to allow for timely delivery of the NOMNC. If the SNF, HHA or CORF assesses a member to be appropriate for discontinuation of services or discharge, the provider will reach out to Mount Carmel MediGold Health Plan three days before the targeted termination date (also known as last covered day). Mount Carmel MediGold Health Plan will review the case with the provider to determine if services will continue or be terminated. If a member files an appeal, the plan must deliver a detailed explanation of why services should end. 

When to Deliver the NOMNC

Providers must deliver a completed copy of the NOMNC to members receiving covered SNF, HHA, and CORF services. The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily.

Providers must deliver the NOMNC to all beneficiaries eligible for the expedited determination process of the Medicare Claims Processing Manual and Chapter 13, Sections 100.2 of the Medicare Managed Care Manual. A NOMNC must be delivered even if the beneficiary agrees with the termination of services. Medicare providers are responsible for the delivery of the NOMNC. The provider must ensure that the beneficiary or representative signs and dates the NOMNC to demonstrate that the beneficiary or representative received the notice and understands that the termination decision can be disputed.

Completed NOMNC’s should be faxed to Mount Carmel MediGold Health Plan Health Services at: Toll Free 1-833-263-4865 and a copy placed in the medical record. 

Notice Delivery to Representatives

CMS requires that notification of changes in coverage for an institutionalized beneficiary/ enrollee who is not competent be made to a representative. Notification to the representative may be problematic because that person may not be available in person to acknowledge receipt of the required notification. Providers are required to develop procedures to use when the beneficiary/ enrollee is incapable or incompetent, and the provider cannot obtain the signature of the enrollee’s representative through direct personal contact. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee’s services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date.

When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested. The date that someone at the representative’s address signs (or refuses to sign) the receipt is the date of receipt. Place a dated copy of the notice in the enrollee’s medical file. When notices are returned by the post office with no indication of a refusal date, then the enrollee’s liability starts on the second working day after the provider’s mailing date.

Exceptions

The following service terminations, reductions or changes in care are not eligible for an expedited review. Providers should not deliver a NOMNC in these instances, when:

  • Services are being reduced (e.g., an HHA providing physical therapy and occupational therapy discontinues the occupational therapy).
  • Beneficiaries are moving to a higher level of care (e.g., home health care ends because a beneficiary is admitted to a SNF).
  • Beneficiaries exhaust their benefits (e.g., a beneficiary reaches 100 days of coverage in a SNF, thus exhausting their Medicare Part A SNF benefit).
  • Beneficiaries end care on their own initiative (e.g., a beneficiary decides to revoke the hospice benefit and return to standard Medicare coverage).
  • A beneficiary transfers to another provider at the same level of care (e.g., a beneficiary transfers from one SNF to another while remaining in a Medicare-covered SNF stay).
  • A provider discontinues care for business reasons (e.g., an HHA refuses to continue care at a home with a dangerous animal or because the beneficiary was receiving physical therapy and the provider’s physical therapist leaves the HHA for another job).

Alterations to the NOMNC

The NOMNC must remain two pages. The notice can be two sides of one page or one side of two separate pages, but must not be condensed to one page. Providers may include their business logo and contact information on the top of the NOMNC. Text may not be moved from page 1 to page 2 to accommodate large logos, address headers, etc. Providers may include information in the optional ‘Additional Information’ section relevant to the beneficiary’s situation.

When to Deliver the DENC

A provider must deliver a completed copy of this notice to beneficiaries/enrollees receiving covered SNF, HHA, and CORF services upon notice from the Quality Improvement Organization (QIO) that the beneficiary/enrollee has appealed the termination of services in these settings. The DENC must be provided no later than close of business of the day of the QIO’s notification.

An Important Message From Medicare About Your Rights (IM)

Hospitals must issue the IM within two calendar days of admission, obtain signature of the patient or the signature of their authorized representative and provide a signed follow-up copy to the patient as far in advance of discharge as possible, but not more than two calendar days before discharge. This letter will include the process to request an immediate review with the appropriate QIO. Members who desire an immediate review must:

  • Submit a request to the QIO, in writing or by telephone, by midnight of the day of discharge.
  • The request must be submitted before the member leaves the hospital.
  • If the member fails to make a timely request to the QIO she or he may request an expedited reconsideration by Mount Carmel MediGold Health Plan.

Availability of Utilization Management Staff

Mount Carmel MediGold Health Plan’s Utilization Management (UM) Department provides medical and support staff resources, including a Medical Director, to process inpatient and outpatient authorizations, answer provider questions, comments, or inquiries, and manage all other UM functions, as appropriate. We are available from 8 a.m. to 4:30 p.m., Monday through Friday, with weekend coverage for CMS-defined expedited requests. Please contact Utilization Management, if needed, at 1-800-240-3870.

Skilled Nursing Facilities (SNF)

Inpatient SNF care includes room and board, skilled nursing care and other customarily provided services in a Medicare Plan.

Three-Day Hospitalization: The Original Medicare requirement of a three (3) consecutive day hospital stay before transferring to a SNF is waived for members.

SNF Prior Authorization and Admission Notification

Mount Carmel MediGold Health Plan no longer requires the prior authorization for Skilled Nursing Facility admission.

We ask that you notify the plan of admission the same day the member arrives at your facility. A clinical update will be required within two business days of admission to your facility. Our team will follow the members stay and provide next review dates with each update.

Admission notifications and updates are preferred through our provider portal, but also accepted via fax and email.Mount Carmel MediGold Health Plan’s fax is 1-833-263-4865, and our shared email address is SNF@MediGold.com. If you are interested in obtaining access to the Essette Provider Portal, please contact the Health Services team at 1-800-240-3870.

Concurrent Review

Concurrent reviews are due on scheduled dates provided by your utilization review nurse. Failure to provide timely updates may result in denied reimbursement for days when skilled criteria is not met. The facility is to notify Mount Carmel MediGold Health Plan of any change in member status or treatment.

Supporting Documentation

Skilled care coverage needs to include sufficient documentation to enable a reviewer to determine whether:

  • Skilled involvement is required in order for the services in question to be furnished safely and effectively; and
  • The services themselves are, in fact, reasonable and necessary for the treatment of a member’s illness or injury, i.e., are consistent with the nature and severity of the individual’s illness or injury, the individual’s particular medical needs and accepted standards of medical practice. The documentation must also show that the services are appropriate in terms of duration and quantity, and that the services promote the documented therapeutic goals.

Tier Reimbursement Model

Please refer to your contract to determine your reimbursement type. If your reimbursement follows the tiered structure, Mount Carmel MediGold Health Plan will utilize 4 Tiers when assigning a daily skilled nursing facility reimbursement rate. Tiers will be assessed and assigned using the Admission Minimum Data Set (MDS), documenting functional status, active diagnoses, current health conditions, swallowing, nutritional status, special treatments, procedures, and enrolled programs. Attributes of the individual Tiers are described below. Examples are not all inclusive. Tier assignments are dependent upon the severity of illness and complexity of care of each member:

Tier 1 and Tier 2 are low to moderately complex stays. Clinical documentation used to assign Tier 1 and Tier 2 reimbursement is derived from Sections GG, I, J, and O of the Admission MDS.

Tier 1 Examples

  • Low complexity cases such as uncomplicated Hip and Knee Replacements
  • Debility, requiring supervision or limited assistance for performance of ADLs.
  • Stable, active diagnoses within the last 7 days such as Stroke and stable neurologic conditions with minimal to no residual effects
  • Stable cardiopulmonary diagnoses such as Pneumonia, CHF, CAD, Hypertension, and PVD
  • Anemia
  • UTI
  • Diabetes
  • CVA with minimal or no residual effects/deficits

Tier 2 Examples

  • Moderate complexity cases such as a Stroke with residual effects/deficits
  • Active Orthostatic Hypotension
  • Debility, requiring extensive assistance or full staff performance of ADLs at every occurrence
  • Cases in which members have had major surgery during the prior inpatient hospital stay and require surgical wound care such as surgery involving the spinal cord or major spinal nerves, some neurosurgery procedures, major cardiac surgery, repair of deep ulcers, bone marrow or stem cell harvest or transplant
  • Septicemia
  • Viral Hepatitis
  • Neurogenic Bladder
  • Isolation and or quarantine for active, infectious disease (does not include standard body/fluid precautions)

Tier 3 are high complexity stays with high cost treatments such as IV medications, tube feedings, complex wound care, trach care. Clinical documentation used to assign Tier 3 reimbursement is derived from Section K, M, and O of the MDS and must be active, while a resident.

Tier 3 Examples

  • Tube feedings: NG or PEG
  • Complex Wound Care (includes Wound Vacs)
  • Tracheostomy care (not on invasive mechanical ventilator support)
  • High cost IV medications
  • Transfusions
  • Chemotherapy and/or Radiation
  • Paraplegia, Hemiplegia or Hemiparesis

Tier 4 stays are members requiring ventilator support. Clinical documentation used to assign Tier 4 reimbursement is derived from Section O of the MDS and must be active, while a resident.

Tier 4 Example

  • Invasive Mechanical Ventilator Support: Weaning, continuous and/or nocturnal only ventilation

Ambulance Services

Ambulance trips to hemodialysis, chemotherapy, radiation therapy, CT or MRI, outpatient surgery or other high end outpatient hospital services should be billed directly by the ambulance company under Medicare Part B. Facilities should use an in-network provider. Ambulance transport from one SNF to another SNF is not covered (unless MediGold determines that there was a quality issue at the first facility). MediGold will review these on a case-by-case basis.

SNF Benefit Period

The Plan covers up to 100 days of care in a Skilled Nursing Facility (SNF) each benefit period. The 100-day benefit period can only be renewed if a beneficiary remains out of an acute case setting including hospital, and SNF consecutively for 60 days.

If a beneficiary’s coverage begins while in an SNF, any SNF days used in that benefit period prior to the member’s effective date will apply toward the 100-day benefit. Should the member be admitted to an acute care hospital from an SNF, for any condition, there will be no days accumulated towards the 100-day benefit period, until the member is discharged back to an SNF.

A new 100-day benefit for a beneficiary can only begin after the consecutive 60 days out of the acute care setting(s) has been satisfied.

Last updated: 04/2024

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