Utilization Review Annual Summary. Utilization review annual summary for 2014.

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Department of Consumer and Business Services

Insurance Division — 2

P.O. Box 14480

Salem, Oregon 97309-0405

Phone: 503-947-7268

Fax: 503-378-4351

350 Winter St. NE, Salem, Oregon

www.insurance.oregon.gov

Utilization Review

Annual Summary

Utilization review annual summary for 2014.

Due on June 30 for previous calendar year.

All health benefit insurers that provide utilization review or have utilization review provided on their behalf shall file an annual summary describing all utilization-review policies and utilization-review monitoring activities, including delegated functions. ORS 743.807, OAR 836-053-1130

1. Company name: Health Republic Insurance Company Filing date: 6/30/2015 2. Company address: 4000 Kruse Way Place, Ste 2-300

City, state, ZIP: Lake Oswego, OR 97035

3. Company Web site: www.healthrepublicinsurance.otg

4. Name, e-mail address, and phone number of the person completing this form: Linda Voelsch, lvoelsch@healthrepublicinsurance.org, 503-345-0102 5. Name, title, and department of manager responsible for oversight of utilization review:

Lauretta Young, MD, Chief Medical Officer, Executive Department

For the following information, enter the URL or the name of the publication in which it appears: 6. Time frame for making utilization review decisions:

Target: 2 business days Actual (average): 3.3 days

URL or the publication title, date, and page:

Policy: UM 60 - Utilization Management (UM) Decision Standards and Timeliness Requirements; 11/2014; pg.1 and 3

7. Specify minimum qualifications for those who make first-level utilization-review decisions:

Non-clinical staff (technicians) can review requests for coverage and approve selected services; they cannot issue denials. Staff follow departmental policies and procedures.

URL or the publication title, date, and page: Desk Procedure: Desk Procedure for Review Process for Prior Authorization Requests; 12/2014; pp.1-2

8. Specify minimum qualifications for those who make second-level utilization-review decisions:

A physician, not involved in the initial clinical determination, reviews the case and makes a determination to uphold or reverse the initial determination. An independent clinician performs a second opinion if requested by a QMM Medical Director or the member.

Desk Procedure: Appeals of Denied UM Services; 10/2014; pp. 5

Policy: UM 90 - Second Opinion and External Review; 06/2014; pp.1-2

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No Yes At which level(s)?

QMM Medical Directors have specific functions and program responsibilities. They participate in the management of medical activities through program evaluation and design, the

development of program clinical content and direction, case review, medical necessity review, and medical policy

development. Medical Directors have responsibility for the Quality Improvement Team (QIT), the Oregon Region Pharmacy and Therapeutics Committee (ORPTC), the Credentials and Quality Committee (CQC), the Technology Assessment

Committee (TAC), the Medical Policy Committee (MPC), and the Medical and Behavioral Health Integration Committee (MBIC). They also represent the organization in the Medical Expense Management Committee (MEMC); in medical group, hospital, and health system-wide initiatives; Medicare and Medicaid quality initiatives, NCQA oversight, and in other external quality organizations.

Medical advisors are generally physicians or other practitioner types, consulted for case review, medical policy and criteria development, evaluation of standards of practice, clinical program development, and nursing staff education. Board certified medical advisors assist with decision making regarding medical appropriateness in their area of clinical expertise and certification. Medical advisors may be members of committees or may attend a committee by invitation, when needed, for specific case review or discussion.

Providence Health Plans 2014 Quality Improvement and Utilization Management Programs Description; 10/2014; pp. 8-9

10. Indicate the sources of clinical information the company researches for utilization-review decisions: Resources consulted for concurrent review and prior authorization include:

- InterQual criteria

- Truven Health Analytics Length of Stay - Milliman Health Care Management Guidelines - MAP Prioritized List of Health Services

- CMS guidelines (e.g.,HCPCS Common Procedure Coding System, coverage of skilled nursing) The following non-inclusive list of technology assessment bodies provides information to the health plan and guides technology coverage decisions:

- National Cancer Institute (NCI)

- Agency for Healthcare Research and Quality (AHRQ) - ECRI Health Technology Assessment Information Service - Hayes Medical Technology Directory

- PubMed database

- Center for Disease Control (CDC) - Federal Drug Administration (FDA) URL or the publication title, date, and page:

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11. List company’s steps in developing utilization-review criteria:

HRIC and its delegates rely on various national criteria sources in addition to internally-developed criteria for the review of medical appropriateness. Both nationally and locally accepted indicators of medical appropriateness (criteria) are used in the review process and decision-making. Criteria as a normative standard provide an evidence-based foundation for utilization management

activities and decision-making, and serve to:

- Educate providers and members about utilization expectations - Provide goals to improve care and processes

- Provide responsible and consistent standards for fair decision making

Review Criteria: The Utilization Management program utilizes local and national standards and criteria for fair and consistent decision-making. The Medical Expense Management Committee through its Medical Policy and Technology Assessment Committee is charged with the

development and approval of medical policy and criteria and for the approval of guidelines for the application of these criteria. The three committees review and update criteria application and medical policy annually, or as needed. Standards, criteria, and medical policy are shared with providers, as they are developed and per request. The application of review criteria is monitored through inter-rater reliability audits performed on both delegated and non-delegated decision makers.

The Medical Expense Management Committee or one of its subcommittees oversees the

development of the medical policy and criteria used for authorizing care. Licensed practitioners with appropriate specialty representation may participate in development of the criteria. Policy and criteria formulation is based on reasonable medical evidence. The health plan adopts nationally-accepted evidenced-based clinical guidelines and criteria and includes the criteria as part of the medical policy and criteria. Guidelines for applying criteria, taking into consideration the individual needs of the member and the capabilities of the local delivery system, are reviewed and approved annually or as needed by the Medical Expense Management Committee. All policies are available to providers via ProvLink, an on-line resource.

New technology and/or new applications of existing technology are evaluated and recommended for coverage by the Technology Assessment Committee. Decisions are based on information from multiple sources such as national assessment bodies, professional societies, accepted experts in the field, consensus of expert opinion and peer-reviewed clinical literature supporting proven health benefit, efficacy, and safety.

Policy: UM 150 - Medical Policy Development and Application; 06/2014; pp.1-3

12. What action or event causes utilization-review criteria to be revised?

The Medical Expense Management Committee through its Medical Policy and Technology Assessment Committee is charged with the development and approval of medical policy and criteria and for the approval of guidelines for the application of these criteria. The three committees review and update criteria application and medical policy annually, or as needed. URL or the publication title, date, and page:

Providence Health Plans 2014 Quality Improvement and Utilization Management Programs Description; 10/2014; pg. 16

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Policy: UM 150 - Medical Policy Development and Application; 06/2014; pp.2-3Policy:

UM 150 - Medical Policy Development and Application; 06/2014; pp.2-3

13. How does the company inform enrollees about changes in utilization-review criteria?

In general, utilization review criteria are a contractual requirement between the health plan and providers; the process is seamless to the member. If a service is denied, the denial letter to the member includes the criteria used to make the decision as well as an explanation of the denial written in lay terms. The letter includes the member’s appeal rights including appeal contact

information and the right to an expedited appeal. Health plan policies, procedures, and criteria are available to members upon request.

In certain instances, specific criteria is provided to members through newsletters, targeted mailings, the website, and benefit booklets.

Providence Health Plans 2014 Quality Improvement and Utilization Management Programs Description; 10/2014; pp.16-18

14. How does the company inform providers about changes in utilization-review criteria?

Standards, criteria, and medical policies are shared with providers as they are published and per request. All medical policies are available to participating providers via the internet (ProvLink). URL or the publication title, date, and page:

Providence Health Plans 2014 Quality Improvement and Utilization Management Programs Description; 10/2014; pp. 18

15. Is there a procedure for monitoring in-house utilization-review criteria?

No Yes Specify:

Criteria application and medical policy are reviewed annually or as needed and updated as necessary. Standards, criteria, and medical policy are shared with providers, as they are developed and per request. The application of review criteria is monitored through inter-rater reliability audits performed on both delegated and non-delegated decision makers.

Providence Health Plans 2014 Quality Improvement and Utilization Management Programs Description; 10/2014; pg. 16

Policy: UM 80 - Inter-Rater Reliability Monitoring for Physician Reviewers; 06/2014; pp.1-2

Policy: UM 81 - Inter-Rater Reliability Monitoring for Nurse Reviewers; 06/2014; pp.1-2

Policy: UM 82 - Inter-Rater Reliability Monitoring for Medical Review Technicians; 06/2014; pp.1-2

16. Does the company delegate any utilization-review activities to outside resources?

No Yes Specify:

UM (including referral management, authorization, case management, and concurrent review) of mental health/chemical dependency services,

alternative care, and requests for selected diagnostic imaging services are delegated to specialty vendors who provide provider networks and related medical management services. There are also specific medical groups that are delegated for select UM services.

Providence Health Plans 2014 Quality Improvement and Utilization Management Programs Description; 10/2014; p. 17-18

Policy: DS 10 - Pre-Delegation of UM Activities; 06/2014; pp.1-3

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No Yes Specify:

The UM program is accountable for approval and oversight of delegated activities to ensure compliance with regulatory and accrediting

requirements. The program policies and program standards must be met by the delegated entities’ medical management programs. Delegated entities provide the health plan with reports on a regular basis; these include denial logs and inter-rater reliability audits. Ongoing assessment of delegation includes onsite visits, audits, and evaluation of program documents and policies. This monitoring process verifies the delegate's ability to administer a UM program. If warranted, revocation of delegation is recommended through the Medical Expense Management Committee.

Providence Health Plans 2014 Quality Improvement and Utilization Management Programs Description; 10/2014; p. 17-18

Policy: DS 10 - Pre-Delegation of UM Activities; 06/2014; pp.1-3

Policy: DS 20 - Continued Delegation of UM Activities; 06/2014; pp.1-3

Policy: DS 30 - Process for Evaluating Delegate's Performance; 06/2014; pp.1-3

Policy: DS 80 - Inter-rater Reliability Monitoring for Delegates; 06/2014, pp.1-2

Policy: DS 100 - Revocation of Delegated Services; 06/2014, pp.1-2

Policy: DS 130 - Process for Intervention Based On Delegate's Unsatisfactory Perfromance Results; 06/2014; pp.1-3