Benefits Plans - Prescription Drug Plan: PA Appeals Process

Page last updated: Tuesday, 02-Sep-2014 13:14:51 EDT

Denials

To check the status of your drug plan Prior Authorization(s), log on the MedImpact website for U-M members at https://mp.medimpact.com/umh

If your request has been denied, you have the option to appeal.

Member Appeal Process for Adverse Benefit Determination

The following appeal process is compliant with the State of Michigan Patient Right to Independent Review Act (PRIRA MCL 550.1951 and MCL 550.1952).

If your doctor has prescribed a medication quantity exceeding the University of Michigan Prescription Drug Plan guidelines, your doctor can call MedImpact Member Services at 1-800-681-9578 to request a “Benefit Exception Form”.

If your doctor prescribes a drug that was not dispensed or was denied Prior Authorization (PA), you may contact MedImpact about an appeal at 1-800-681-9578.

If your doctor has prescribed a medication that is specifically excluded from coverage in the University of Michigan Prescription Drug Plan and you want to appeal the decision, you may contact MedImpact at 1-800-681-9578 for a written notice of right to appeal.

Appeal Process First Level – Prior Authorization or Benefit Exception

If you want to appeal a prescription drug Prior Authorization denial or a Benefit Exception denial, follow the instructions in the denial letter. You may also call MedImpact Member Services at 1-800-681-9578 to request a copy of the first level appeal form.

You may authorize in writing any person such as your doctor, attorney, parent or spouse to represent you in the appeal process. You or your authorized representative must complete and sign the appeal form allowing MedImpact to disclose Protected Health Information necessary for the appeal. [MCL 550.1907(c)]
Your first level appeal will be reviewed by an MedImpact health care professional.

  • The first level appeal determines if the requested use meets the university’s plan design, formulary, limitations and the standard indications such as Food and Drug Administration and manufacturer recommendations.

The first level appeal will be completed within 15 days.

  • The written notice of appeal determination will be mailed to you and your doctor.
  • If your appeal is denied you have 180 days from the issue date of the original denial to submit a second level appeal based on "medical necessity." 

Urgent Appeal: When an appeal involves a medical condition for which the time frame for completion of the appeal would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function , an ‘urgent appeal’ can be requested which can be completed within 72 hours.
Patient specific information regarding your appeal is not shared with the University of Michigan by MedImpact.

If you have an existing prescription for a medication covered by the plan (not a new prescription), the university will provide you a 30-day override for your medication until your appeal is reviewed. To obtain a continuation override during the appeal process, contact the Benefits Office at 866-647-7657.

Appeal Process Second Level - Medical Necessity

If a First Level Appeal has been denied for your medication, you or your authorized representative may call MedImpact Member Services at 1-800-681-9578 to request a second level independent external review.
A second level appeal is reviewed by an independent specialist doctor outside of MedImpact. This includes a review of any medical records provided, a review of the medical literature, and discussion of the medical necessity request with your doctor. Medical necessity means that there is solid, credible evidence for the use of the drug as requested for your condition.

  • The second level appeal review will be completed within 15 days. You and your doctor will receive a written rationale in support of the final decision.
  • If the second level appeal is denied, you or your authorized representative has 60 days from the date you received the final determination to request a State of Michigan External Claim Review (Appeal Process Third Level).
  • If you have a medical condition where the time frame for completion of an expedited internal grievance would seriously jeopardize your life or health or your ability to regain maximum function, as substantiated by a doctor either orally or in writing, you or your representative may file a request for an expedited external review by Michigan OFIR at the same time as you file a request for an expedited second level appeal for medical necessity by MedImpact.

Patient specific information regarding your appeal is not shared with the University of Michigan by MedImpact.

Appeal Process Third Level – State of Michigan External Claim Review

With respect to any health care benefits insured by a company subject to the insurance laws and regulations of the State of Michigan, if you disagree with the prescription drug plan’s final decision following whatever required or voluntary levels of appeal are available, or your request for review at the first or second level has not been completed within the time frame above, you may request an external review from the Michigan Office of Financial and Insurance Regulation (“OFIR”).  Once you have exhausted the internal appeal procedures described above, you or your authorized representative has the right to request an external review from OFIR.  OFIR’s decision is the final administrative remedy under Michigan’s Patient’s Right to Independent Review Act (PRIRA). This external review procedure is voluntary and you are not required to seek to have your Claim reviewed under this procedure.

Within 60 days of the date you either received a final determination on appeal, or should have received it, you or your authorized representative may send a written request for an external review to OFIR.  Mail your request, including the required forms that may be obtained from the OFIR Claims Administrator, to:

Office of Financial and Insurance Regulation (OFIR)
Office of Policy, Conduct and Consumer Assistance, Health Plans Division
Benefit Inquiry Section
P.O. Box 30220
Lansing, MI 48909-7720
(877) 999-6442

These items may be requested for consideration in the external claim review:
(a) Your pertinent medical records.
(b) The attending health care professional's recommendation.
(c) Consulting reports from appropriate health care professionals and other documents submitted by the prescription drug plan, you, your authorized representative, or your treating provider.
(d) The terms of coverage under your prescription drug plan.
(e) The most appropriate practice guidelines, which may include generally accepted practice guidelines, evidence-based practice guidelines, or any other practice guidelines developed by the federal government or national or professional medical societies, boards, and associations.
(f) Any applicable clinical review criteria developed and used by the prescription drug plan or its designee utilization review organization.

If your request is not accepted for external review because the request is not complete, OFIR shall inform you and, if applicable, your authorized representative what information or materials are needed to make the request complete. If a request is not accepted for external review, the commissioner shall provide written notice to you and if applicable your authorized representative, and the prescription drug plan of the reasons for its non-acceptance.

If your request for external review involves an issue of medical necessity or clinical review criteria, and is otherwise found to be appropriate for external review (a decision to be made by OFIR), OFIR will send your Claim to an independent organization to conduct an external review (“IRO”), consisting of independent clinical peer reviewers.  After OFIR has decided to accept your case for external review, you will have an opportunity to provide additional material to OFIR within seven days after your request is accepted.  The insurance carrier must give documents and information which it considered in making its final determination to the IRO within seven business days after it receives notice of your request to the Commissioner.  The IRO will recommend, within 14 days, whether OFIR should uphold or reverse the insurance carrier’s determination of your Claim.  OFIR must then decide within seven business days whether or not to accept the IRO’s recommendation and will notify you of its decision. 

Not later than 5 business days after the date of receipt of a request for an external review, OFIR shall complete a preliminary review of the request to determine all of the following [MCL 550.1911(2)]

(a) Whether you were a covered person in the prescription drug plan at the time the prescription was requested or, in the case of a retrospective review, were a covered person in the prescription drug plan at the time the prescription was provided.
(b) Whether the prescription that is the subject of the adverse determination or final adverse determination reasonably appears to be a covered service under your prescription drug plan.
(c) Whether you have exhausted the health carrier's internal grievance process unless you are not required to exhaust the health carrier's internal grievance process.
(d) You have provided all the information and forms required by the commissioner that are necessary to process an external review, including the health information release form.
(e) Whether the prescription that is the subject of the adverse determination or final adverse determination appears to involve issues of medical necessity or clinical review criteria.
If your request for external review does not appear to involve issues of medical necessity or clinical review criteria, and is otherwise found to be appropriate for review, OFIR’s staff may conduct the external review or OFIR may assign an independent organization (IRO) to conduct the external review.  The reviewer will then recommend whether OFIR should uphold or reverse the prescription drug plan’s determination.  OFIR will notify you of the decision, and that decision is your final administrative remedy.

You or your authorized representative may make a request for an expedited external review with OFIR within 10 days after you receive an adverse determination if:
(a) The adverse determination involves a medical condition for which the time frame for completion of an expedited internal grievance would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function as substantiated by a doctor either orally or in writing;
(b) You or your authorized representative has filed a request for an expedited internal grievance.
An expedited external review shall not be provided for retrospective adverse determinations or retrospective final adverse determinations.

Contact the Claims Administrator (phone (877) 999-6442) to find out what you are required to do to receive a review:

Office of Financial and Insurance Regulation (OFIR)
Office of Policy, Conduct and Consumer Assistance, Health Plans Division
Benefit Inquiry Section
P.O. Box 30220
Lansing, MI 48909-7720

Immediately after receiving your request for an expedited review, the OFIR will decide if your Claim is appropriate for external review and assign it to an IRO.  If the IRO decides that you do not have to first complete the expedited internal review procedure, it will review your request and make its recommendation to the OFIR within 36 hours.  The OFIR must then decide within 24 hours whether or not to accept the recommendation of the IRO.  The OFIR’s decision is the final administrative remedy under Michigan’s Patient’s Right to an Independent Review Act (PRIRA).

An external review decision and an expedited external review decision are the final administrative remedies available under this act. A person aggrieved by an external review decision or an expedited external review decision may seek judicial review no later than 60 days from the date of the decision in the circuit court for the county where you resides or in the circuit court of Ingham county. You may also seek other remedies available under applicable federal or state law.

You or your authorized representative may not file a subsequent request for external review involving the same adverse determination or final adverse determination for which you have already received an external review decision.

 

 

Limitations
The University of Michigan in its sole discretion may modify, amend, or terminate the benefits provided with respect to any individual receiving benefits, including active employees, retirees, and their dependents. Although the university has elected to provide these benefits this year, no individual has a vested right to any of the benefits provided. Nothing in these materials gives any individual the right to continued benefits beyond the time the university modifies, amends, or terminates the benefit. Anyone seeking or accepting any of the benefits provided will be deemed to have accepted the terms of the benefits programs and the university's right to modify, amend or terminate them.