First Priority Health (FPH) realizes that health care is rapidly changing and often challenging. As your partner in health care, FPH offers various internal avenues for providers to render an appeal, non medical or processing appeals, (section #1) and medical determination appeals (Informal Dispute Resolution or Provider Initiated Member appeals), (section #2).

1. There are (3) three types of appeals that do not involve determination of medical necessity. Claim Administrative Appeals, PACE Process Appeals and Appeals of Sanctions or Terminations.

1. Administrative Claim Process Appeals – These types of appeals include claim processing including denials for timely filing, questionable level of payment or failure to obtain necessary authorization for non-emergency services. Provider Relations shall provide oversight of all appeals. A record keeping and reporting system shall be in place for all appeals. There will be no further levels of appeals. The provider appeal(s) will be received in Provider Relations and forwarded to the designee. The designee will then gather any and all related information from the provider and any department within First Priority Health.

All information shall immediately be presented to the appropriate Regional Manager. Written notification of the final decision shall be sent to the appealing entity within ninety (90) business days from date of the appeal letter Written Administrative Appeals can be sent to:

First Priority Health
Provider Relations Department
19 N. Main Street
Wilkes-Barre, PA 18711-0302

2. PACE Process Appeals - First Priority Health has been processing claims on Facets, an integrated processing system since November 19, 2001. The Facets has PACE as its clinical editor. It was developed and maintained by PACE Healthcare Management. PACE contains both clinical criteria and claim editing criteria. Please refer to your Provider Bulletins for more information on PACE.

As with all clinical editors, the Pace Clinical Editor database contains hundreds of thousands of edits relating to procedure coding practices. The clinical editor is based on the coding criteria and protocols in the CPT-4 manual, which is published by the American Medical Association. The database is updated annually in response to each year’s release of the updated CPT coding manual.

If your facility receives a PACE edit denial, the appropriate denial code will appear on your Remittance Advice (RA) Statement. If there is disagreement with the reason for the denial, an appeal can be made.

To submit a PACE appeal, the following documentation is required to be submitted 90 days from the date of the RA:

• a letter identifying the specific coding combination and supporting physician rationale for payment for the denied code(s);
• a copy of the original claim form, or a new claim form which is identical to the original submission;
• medical record documentation from the patient’s chart; and
• mandatory Claims Research Request Form with the appropriately checked box.

Appeals must be submitted within ninety (90) days from the date of the RA and will be reviewed by a Clinical Coordinator and if necessary, an FPH Medical Director. Appeals submitted without all of the necessary documentation or after the 90-day limit has expired, are not eligible for consideration and will be returned to your office. The decision will be final. All appeals will be processed within thirty (30) days of receipt.

First Priority Health
Claims Research Department
19 North Main Street
Wilkes-Barre, PA 18711-0302

3. Administrative -Termination Dispute Process - This is the third type of non –medical determination appeal. There are several sources for your reference:

1. Please refer to Section P, "Policies", of this manual.
2. Also refer to your executed FPH Agreement, "Termination" section and the appropriate attachments to your executed agreement:
   

If you are unable to locate any of the above agreement references, please contact BCNEPA Provider Relations at 570-200-4700 or 1-800-451-4447.

2. For appeals related to medical decisions, a provider may choose one of two (2) avenues, Informal Dispute Resolution Process (IDR) OR Provider –Initiated Member Appeals (Act 68). Providers may appeal Utilization Management decisions through the IDR process OR the Act 68 process to contest medical necessity decisions. Examples include a decision made regarding an admission, level of care or other health care service based upon the review of available information. The IDR process does not apply if the Member Appeal Process has been initiated. Providers must select either the Informal Dispute Resolution Process OR the Provider-Initiated Member Appeal Process. Providers cannot use both methods for the same member.

1. Informal Dispute Resolution Process (IDR) – Expedited (Urgent) Appeal – If a provider feels the decision in dispute is about urgent or potentially emergent care, the provider may request an Expedited or Urgent IDR Appeal by calling the FPH Medical Director at 1-800-462-0900 within one (1) business day of the initial decision. The provider discusses the appeal with the FPH Medical Director who made the initial decision, whenever possible. If the initial appeal decision is not satisfactory, the FPH Medical Director informs the provider of the right to initiate a standard appeal.
   
   
2. Informal Dispute Resolution Process (IDR) – Standard Appeal – If a provider wishes to contest a medical necessity decision and it does not involve urgent/emergent care, the provider may request a standard IDR appeal within sixty (60) days from the date of the initial decision. The provider may mail or fax their written appeal request to:

First Priority Health
Regulatory Compliance Department
19 N. Main Street
Wilkes-Barre, PA 18711-0302
FAX: 570-200-6755

Please include the following information in the written request: member name and FPH ID#, provider name and FPH Provider ID#, provider’s address, phone number, fax number, (if applicable), requested procedure or service, date of denial, diagnosis and medical justification for the procedure or service, copies of entire medical record/physician office notes, and a copy of the original denial.

The FPH Medical Director reviews all information and renders a final decision. The review, decision and written notification to the requesting provider will occur within 30 (thirty) days of receipt of the written appeal request. There are no other provider appeal mechanisms after this final decision is rendered.

b. Provider Initiated Member Appeals (Act 68) - Pennsylvania Act 68 gives providers the right, with the written permission of the member, to pursue an appeal in lieu of the member. A provider may ask for a member’s written consent in advance of treatment but may not require a member to sign a document allowing the filing of a grievance as a condition of treatment. The regulatory requirements for providers apply to items that must be in the document giving the provider permission to pursue a grievance, and the time frames for member notification of provider intent to pursue or not pursue a grievance. These are important because under this scenario, the provider assumes the grievance and appeal rights of the member. However, the member may rescind the consent at any time.

A PROVIDER WHO USES THIS PROCESS TO FILE AN APPEAL MAY NOT ALSO, FOR THE SAME MATTER, USE THE PROVIDER IDR PROCESS DESCRIBED ABOVE IN SECTION 2A.

If a health care provider assumes responsibility for filing a grievance, the health care provider may not bill the member for services that are the subject of the grievance until the external grievance review has been completed or the member rescinds consent for the health care provider to pursue the grievance.

If the health care provider elects to appeal an adverse decision made by the plan or a certified review entity (CRE), the health care provider may not bill the member or member’s legal representative for services provided that are the subject of the grievance until the health care provider chooses not to appeal an adverse decision to a court of competent jurisdiction.

If the health care provider is prohibited from billing the member or chooses never to bill the member for the services that are the subject of the grievance, the health care provider may drop the grievance with notice to the member or the member’s legal representative.

Any member can ask another person to act as his/her representative in the appeals process ("member’s representative"). If this representative is a health care provider, the provider must obtain the member’s written consent to pursue a grievance. The member’s or the member’s legal representative’s, if the member is a minor or is legally incompetent, consent to a health care provider to pursue a grievance must be in writing, and the consent is automatically rescinded upon the failure of the health care provider to file or pursue a grievance.

The consent document giving the health care provider authority to pursue a grievance on behalf of a member must include each of the following elements:

1. The name and address of the member, the member’s date of birth and the member’s identification number.
2. If the member is a minor, or is legally incompetent, the name, address and relationship to the member of the person who signs the consent for the member.
3. The name, address and identification number of the health care provider to whom the member is providing the consent.
4. The name and address of the plan to which the grievance will be submitted.
5. An explanation of the specific service for which coverage was provided or denied to the member to which the consent will apply.

The following statements must be in the consent document:

1. The member or the member’s representative may not submit a grievance concerning the services listed in this consent form unless the member or the member’s legal representative rescinds consent in writing. The member or the member’s legal representative has the right to rescind consent at any time during the grievance process.
2. The consent of the member or the member’s legal representative is automatically rescinded if the provider fails to file a grievance, or fails to continue to prosecute the grievance through the second level review process.
3. The member or the member’s legal representative, if the member is a minor or is legally incompetent, has read, or has been read this consent form, and has had it explained to his/her satisfaction. The member, or the member’s legal representative understands the information in the member’s consent form.

The consent document must also have the dated signature of the member, or the member’s legal representative if the member is a minor or is legally incompetent, and the dated signature of a witness. The member may rescind consent at any time during the grievance process. If the member rescinds consent, the member may continue with the grievance at the point at which consent was rescinded. The member may not file a separate grievance. A member who has filed a grievance may, at any time during the grievance process, choose to provide consent to a health care provider to continue with the grievance instead of the member. The member’s legal representative may exercise the rights conferred upon the member.

The member, member’s representative, or health care provider with written consent of the member, may file a written grievance with First Priority Health. A grievance is a request to First Priority Health to reconsider a decision solely concerning the medical necessity and appropriateness of a health care service. A grievance may be filed regarding a decision to:

1. deny, in whole or in part, payment for a service (if based on lack of medical necessity)
2. deny or issue a limited authorization of a requested service, including the type or level of service
3. reduce, suspend, or terminate a previously authorized service
4. deny the requested service but approve an alternate service.

The member, member’s representative, or health care provider with written consent of the member, must file a grievance within 180 days of the utilization management decision or from the date of receipt of notification about the utilization management decision.

There is also an Expedited Grievance Process detailed at the end of this section.

The provider, having obtained consent from the member or the member’s legal representative to file a grievance, has 10 days from receipt of the standard written denial and any decision letter from a first level, second level, or external review to notify the member or the member’s legal representative of its intention not to pursue a grievance.

First Priority Health will send written confirmation of its receipt of the grievance to the member, the member’s representative (if the member has designated one), and the health care provider, if the health care provider filed the grievance with member consent upon receipt of the grievance. The notification will include the following information:

• That First Priority Health considers the matter to be a grievance (rather than a complaint). The member, the member’s representative, or health care provider, may question the classification of complaints and grievances by contacting the Pennsylvania Department of Health.
• That the member may appoint a representative to act on the member’s behalf at any time during the internal grievance process.
• That the member, the member’s representative, or the health care provider that filed the grievance with member’s consent, may review information related to the grievance upon request and submit additional material to be considered by First Priority Health.
• That the member or the member’s representative may request the aid of a First Priority Health employee who has not participated in the utilization management decision to assist in preparing the member’s first level grievance.

The first level grievance review shall be performed by an initial review committee. The members of the committee will not have been involved in any prior decision relating to the grievance. The committee will include a licensed physician or an approved licensed psychologist, practicing in the same or similar specialty that would typically consult on the health care services in question. An approved licensed psychologist may perform UR for a behavioral health care service within the psychologist’s scope of practice if the psychologist’s clinical experience provides sufficient expertise to review that specific behavioral health care service. An approved licensed psychologist may not review the denial of payment for a health care service involving inpatient care or a prescription drug.

First Priority Health will provide the member, the member’s representative, or a health care provider that filed a grievance with member consent, access to all information relating to the matter being grieved and will allow the provision of written data or other material in support of the grievance. The member, the member’s representative, or the health care provider may specify the remedy or corrective action being sought.

First Priority Health will provide, at no charge, at the request of the member or the member’s representative, an employee who has not participated in previous denial decisions regarding the issue in dispute, to aid the member or the member’s representative in preparing the member’s grievance.

First Priority Health will complete its review and investigation, and arrive at a decision within 30 days of receipt of the grievance. First Priority Health will notify the member, the member’s representative, and the health care provider of the decision of the internal review committee in writing within 5 business days of the committee’s decision. The notice to the member, the member’s representative, and the health care provider, will include the basis for the decision and the procedures for the member or provider to file a request for a second level review of the decision of the initial review committee including:

• A statement of the issue reviewed by the first level review committee
• The specific reasons for the decision
• References to the specific First Priority Health provisions on which the decision is based and how to obtain these documents, if used
• An explanation of the scientific or clinical judgment for the decision
• An explanation of how to file a request for a second level review of the decision which must be filed within 180 days of the first level decision.

Upon receipt of a voluntary second level grievance, First Priority Health will send the member, the member’s representative, and the health care provider, an explanation of the procedures to be followed during the second level review. This explanation will include the following information:

• How to request the aid of a First Priority Health employee who has not participated in any discussion of the issue in dispute in preparing the member’s second level grievance.
• Notification that the member, the member’s representative, and the health care provider have the right to appear before the second level review committee and that First Priority Health will provide the member, the member’s representative, and the health care provider with 15 days advance written notice of the time scheduled for the review.

The second level review committee shall be made up of three or more individuals who did not previously participate in the decision to deny coverage or payment for the issue in dispute. The committee will include a licensed physician or a licensed psychologist, practicing in the same or similar specialty who would typically consult on the health care services in question. An approved licensed psychologist may perform UR for a behavioral health care service within the psychologist’s scope of practice if the psychologist’s clinical experience provides sufficient expertise to review that specific behavioral health care service. An approved licensed psychologist may not review the denial of payment for a health care service involving inpatient care or a prescription drug.

The second level review allows the following:

• The member, the member’s representative, and the health care provider have the right to be present at the second level review, and to present a case.
• First Priority Health shall notify the member, the member’s representative, and the health care provider at least 15 days in advance of the date scheduled for the second level review.

First Priority Health will make reasonable accommodation to facilitate the participation of the member, the member’s representative, and the health care provider by conference call or in person. First Priority Health will take into account the member’s access to transportation and any disabilities or language barriers. If the member, the member’s representative or filing health care provider cannot appear in person at the second level review, First Priority Health will provide the member, the member’s representative or the provider, the opportunity to communicate with the review committee by telephone or other appropriate means.

Attendance at the second level review is limited to:

• members of the review committee
• appropriate First Priority Health representatives
• the member, or the member’s representatives, including any legal representative and/or attendant necessary for the member to participate in or understand the proceedings
• the health care provider who filed the grievance with the member’s consent
• applicable witnesses.

The committee may not discuss the case to be reviewed prior to the second level review meeting. A committee member who does not personally attend the review meeting may not vote on the case unless that person actively participates in the review meeting by telephone or videoconference and has the opportunity to review any additional information introduced at the review meeting prior to the vote. First Priority Health may provide an attorney to represent the interests of the committee but the attorney may not argue First Priority Health’s position, or represent First Priority Health or First Priority Health staff. The committee may question the member, the member’s representative, the health care provider, and First Priority Health staff. The committee will base its decision solely upon the materials and testimony presented at the review. The proceedings will be transcribed. The transcription will be maintained as a part of the grievance record to be forwarded upon a request for an external grievance review.

First Priority Health will complete the voluntary second level grievance review and arrive at its decision with 45 days of receipt of the grievance. First Priority Health will notify the member, the member’s representative, and the health care provider of the decision of the second level review committee in writing within 5 business days of the committee’s decision.

First Priority Health will include the basis for the decision and the procedures and time frames for the member. the member’s representative, or the health care provider, to file a request for an external grievance review including the following:

• A statement of the issue reviewed by the second level review committee
• The specific reasons for the decision
• References to the specific First Priority Health provisions on which the decision is based and how to obtain these documents, if used
• An explanation of the scientific or clinical judgment for the decision, applying the terms of the plan to the member’s medical circumstances.
• A statement that the member has 15 days from receipt of the second level grievance review to file a request for an external review with the plan.
• A statement that the member can request an external review by either calling or writing First Priority Health. The address and phone number are provided in the letter.

The member, member’s representative, or health care provider with written consent of the member can file an Expedited Grievance with First Priority Health by calling First Priority Health. The member, member’s representative, or health care provider with written consent of the member may request an expedited review at any stage of the plan’s review process if the member’s life, health or ability to regain maximum function would be placed in jeopardy by delay occasioned by the review process. In order to obtain an expedited review, the member, the member’s representative or the health care provider, with the written consent of the member, must provide First Priority Health with a written certification from the member’s physician that the member’s life, health, or ability to regain maximum function would be placed in jeopardy by delay. The certification must include the clinical rationale and facts to support the physician’s opinion.

The expedited grievance will be put into written form and be reviewed by the Medical Director. The Expedited Grievance Process will follow the process described above in Provider-Initiated Member Appeals (Act 68 Process) – Second Level Review, with the following exceptions:

• Time frame is 48 hours for a decision.
• The hearing may be held telephonically if the member cannot be present in the short time frame (all information presented at the hearing is read into the record).
• If First Priority Health cannot provide a copy of the report of the same or similar specialist to the member prior to the expedited hearing, the plan may read the report into the record at the hearing, and shall provide the member with a copy of the report at that time.
• It is the responsibility of the member, the member’s representative, or the health care provider to provide information to First Priority Health in an expedited manner to allow the plan to conform to the requirements of this section.

An expedited internal second level review will be conducted within 48 hours of receipt of the request from the member, the member’s representative, or health care provider, with written consent of the member, for an expedited review accompanied by a physician’s certification. The notification to the member, member’s representative, or health care provider will state the basis for the decision, including any clinical rationale, and the procedure for obtaining an expedited external review. The member, member’s representative, or health care provider with written consent of the member, has 2 business days from the receipt of the expedited grievance decision to request an expedited external review.

For Expedited External Review requests, First Priority Health will submit a request for an expedited external review to the Pennsylvania Department of Health by fax transmission and telephone within 24 hours of receipt of the member’s, member’s representative, or health care provider’s, with written consent of the member, request. The Department of Health will assign a certified review entity (CRE) within 1 business day of receiving the request for an expedited review. The CRE will have 2 business days following the receipt of the case file to make a decision.

Pennsylvania Act 68 allows for an external grievance process by which a First Priority Health member, member’s representative, or a health care provider, with the written consent of the member, may request an external review of a denial of a second level grievance. The external grievance process shall adhere to the following standards:

A member, the member’s representative or the health care provider who filed the grievance, have 15 days from receipt of the second level grievance review decision to file with First Priority Health a request for an external review. If the request for an external grievance is being filed by a health care provider, the health care provider shall provide the name of the member involved and a copy of the member’s written consent for the health care provider to file the external grievance.

Within 5 business days of receiving the external grievance from the member or health care provider filing a grievance with member consent, First Priority Health will notify the Pennsylvania Department of Health, the member and the health care provider that a request for an external grievance review has been filed. First Priority Health’s notification to Pennsylvania Department of Health by phone and fax shall include a request for assignment of a certified review entity (CRE). First Priority Health will notify the provider or the member of the name, address and phone number of the assigned CRE within 2 business days.

First Priority Health will, within 15 days of request for an external review, forward the case file to the assigned CRE. First Priority Health will also send the provider or member a listing of all documents forwarded to the CRE. Once the CRE reaches its decision, First Priority Health will authorize a health care service and pay claim(s) determined to be medically necessary and appropriate by the CRE whether or not First Priority Health appeals the CRE’s decision to a court of competent jurisdiction. The assigned CRE will review and issue a written decision within 60 days of the filing of the request for an external grievance review. The decision will be sent to the member and the member’s representative, the health care provider, the plan, and the Pennsylvania Department of Health.

First Priority Health contracts directly with behavioral health care providers in order to offer members comprehensive behavioral healthcare services.

Access to these services is through our agreement with Community Behavioral Healthcare Network of Pennsylvania (CBHNP).

The responsibilities of CBHNP are to:

• Verify member eligibility and benefits
• Triage and refer member requests for services
• Authorize, review and approve treatment plans

This centralized system for coordination of services ensures that members will be evaluated and referred to the most appropriate participating facility or professional in a timely manner. Throughout the course of treatment or hospitalization, CBHNP will review the member's progress within the established plan of treatment, and authorize the use of the member's benefits according to established criteria.

Either the member, primary care physician, employee assistance representative, family member or a mental health provider must contact CBHNP for:

• Authorization for all outpatient and partial hospitalization services
• Pre-admission certification for inpatient psychiatric and chemical recovery services
• Inpatient detoxification/rehabilitation services

*** The only prerequisite before an insured obtains non-hospital residential and outpatient coverage for alcohol and drug dependency treatment is a certification and referral from a licensed physician or licensed psychologist. The certification controls the nature and duration of the treatment.

All other requests for Drug and Alcohol treatment by other than a licensed physician or licensed psychologist must be pre-certified by CBHNP before services are rendered and must meet medical necessity criteria. In all instances, services must be performed by a participating provider.

CBHNP can be contacted:

24 Hours a Day
7 Days a Week
1-800-599-2428

Upon request, criteria for inpatient mental health services can be obtained by contacting CBHNP at 1-800-599-2428. For chemical recovery services, First Priority Health uses the American Society of Addiction Medicine criteria for any level of care. For information on how to obtain this criteria, also contact CBHNP.

REQUESTING MEDICAL CRITERIA

CBHNP base its Behavioral Healthcare decisions on specific criteria to determine medical necessity. These criteria are available to all FPH providers upon request.

Criteria may be requested by either contacting or faxing CBHNP with the following information: member's name, FPH identification number, date(s) of service, date(s) of denial and facility where services were rendered or by calling the Provider Services Unit at 1-800-822-8752.

CBHNP/Regional Referral Center
3 West Olive Street, Suite 107
Scranton, PA 18508
Phone - 1-800-599-2428
Fax - 1-888-548-8013

All Chemical Recovery treatment programs must be appropriately licensed by the Department of Health Bureau of Drug and Alcohol.