PEER REVIEW PROCESS
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In cases in which the proposed treatment does not meet Medical Necessity Criteria for certification, the case is referred to a Peer Advisor who will then render the service certification or non-certification decision. Peer Advisors are licensed and have appropriate clinical experience. They will perform reviews within the scope of their licensure according to Act 68. A Peer Advisor will be available 24 hours a day.
A Peer Advisor may also request and review additional information, including all or portions of the provider’s medical records/clinical notes.
A Service Manager / CAFT Coordinator will advise the requesting provider that the case will be referred to a Peer Advisor and give the provider the applicable time frame in which the review will occur. For inpatient, crisis stabilization, or non-hospital D&A residential requests when the member is already admitted, the peer review will be conducted within 24 hours. If an admission is pending the decision of peer review, the review will be done within one (1) hour. For other requests, the Peer Advisor will be contacted and a review scheduled. The Peer Advisor will then complete the review with the requesting provider within two (2) business days. All clinical documentation is entered into the care management system within 24 hours of the review.
The Service Manager will review the Peer Advisor’s discussion with the provider, the decision, the treatment plan recommendations, and the issues for the next review. Two decisions can be rendered by the Peer Advisor: Approval (Certification) or Denial (Non-Certification).
Approval (Certification)
If an approval is issued, the Peer Advisor will advise the provider of the determination and the number of days/sessions that are approved. The Service Manager will then build an authorization for these approved days/sessions in CareConnect and an authorization letter will be mailed to the provider the next business day.
Denial (Non-Certification)
If any or all of the requested care is denied, the Peer Advisor will communicate the non-certification and the clinical basis for the denial to the provider. The Service Manager will then notify the member, facility and/or provider with a non-certification letter and/or fax. The letter and/or fax will be sent to the member on the same day the denial decision is made for all acute levels of care and within two (2) business days of the denial decision for non-acute levels of care. If the member has been receiving services that have been modified or have been determined not to meet Medical Necessity Criteria based on the benefit allowed, and the member or an advocate, with the member’s written permission, files a grievance or DPW fair hearing request that is hand-delivered or postmarked within ten (10) calendar days of the date this notice is mailed, the services will continue until a decision on the grievance or fair hearing is made, or until the current service prescription expires. For inpatient denials, the grievance must be filed prior to the effective date of the denial notice. Services will continue until a decision on the grievance or fair hearing is made, or until the current service prescription expires. If the member wishes to file a grievance either verbally or in writing, the Peer Advisor Coordinator will initiate the Grievance Level I process. |
