Determination Notices

Notices may or may not be required for services that were approved as requested.  In case of modifications or denials, written notices are required.  It is not unusual for UR nurses/clinical professionals performing case reviews to also be responsible for composing draft notices for adverse (unfavorable, in full or in part) decisions. Draft notices are typically composed by UR professionals reviewing cases to facilitate the decision-making process of the final decision maker. Draft notices must be professional and should be clear, concise, and understandable to reader. Therefore, it is essential for UR professionals to understand the essential content of a notice. 

In general, all adverse notices must contain clear and concise explanation of the reason(s) for the decision. As always, adverse medical necessity decisions must be ultimately determined and signed off by the appropriate professional noted in the section, Medical Necessity Review. In addition, the notice must meet Timelines for Decision standards.

An organization determination is any determination (i.e., an approval or denial) made by an MA

plan, or its delegated entity with respect to the following:

• Payment for temporarily out of the area renal dialysis services, emergency services, post stabilization care, or urgently needed services;
• Payment for any other health services furnished by a provider (other than the MA plan), that the enrollee believes are covered under Medicare, or if not covered under Medicare, should have been furnished, arranged for, or reimbursed by the MA plan.
• Refusal to authorize, provide, or pay for services, in whole or in part, including the type or level of services, which the enrollee believes should be furnished or arranged by the MA plan;
• Reduction, or premature discontinuation, of a previously authorized ongoing course of treatment; or
• Failure of the MA plan to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide timely notice of an adverse determination, such that a delay would adversely affect the health of the enrollee.

Standardized Integrated Denial Notice (IDN)/Notice of Medicare Non Coverage (NOMNC), must contain the following:

• A specific and detailed explanation of why the medical services and/or items were denied, including a description of the applicable coverage rule or applicable plan policy (e.g., Evidence of Coverage provision) upon which the action was based; and if applicable, a specific explanation about what information would be needed to approve coverage;
• If applicable, an explanation of a provider’s refusal to furnish an item or service.

The below must also be included but are usually already noted in the Plan's Notice templates: 

• Information regarding the enrollee’s right to appeal and the right to appoint a representative to file an appeal on the enrollee’s behalf; 
• For service denials, a description of both the standard and expedited appeal processes, including the specific department or address for reconsideration requests and a description of conditions for obtaining an expedited reconsideration, the timeframes for each, and the other elements of the appeals process;
• The enrollee’s right to submit additional evidence in writing or in person.

There are specific requirements for the content of a Notice of Action (NOA).  Medi-Cal provides NOA templates. However, the Plan is responsible for inserting all of the following into the notice:

• The action taken, such as a deny, modify, terminate, defer, carved out, etc. (which is noted on the NOA templates)
• A clear and concise explanation of the reasons for the decision.
• A description of the criteria or guidelines used. This includes a reference to the specific regulation or authorization procedures that support the decision, as well as an explanation of the criteria or guideline.
• The clinical reasons for the decision, which should explicitly state how the member’s condition does not meet the criteria or guidelines.

The below items must also be included in the NOA but are usually already embedded in the Plan's version of the NOA templates:

• Rights to request free of charge copies of all documents and records relevant to the NOA, including criteria or guidelines used. 
• Appeal and fair hearing rights and timelines (usually part of the NOA template).
• For written notification to the requesting provider (the requestor), the name and direct telephone number or extension of the decision maker. 

Decisions shall be communicated to the member in writing. In addition, decisions shall be communicated to the provider initially by telephone or facsimile, and then in writing. Decisions rendered retrospectively only need to be communicated to requesting providers in writing.