KEY TERMS YOU SHOULD KNOW- Managed Care Health Insurance Plan

KEY TERMS YOU SHOULD KNOW

 

Managed Care Health Insurance Plan (MCHIP) – a health carrier, such as a Health
Maintenance Organization (HMO) or a Preferred Provider Organization (PPO), that
designs arrangements to provide covered services and medications in an efficient
and cost-effective manner, to help control the cost of your coverage.

Adverse decision – The initial or subsequent denial of services or medications by
your MCHIP.

Appeal – You and/or your physician may appeal an adverse decision made by
your MCHIP.  For a medicationdenial, it is usually best if the prescribing physician makes
the first appeal by telephone to the MCHIP’s Medical Director.  If this appeal is
denied, you will normally have at least one additional level of appeal to your MCHIP.

Clinical information – Your medical records documenting past drug trials and health history.
Your prescribing physician should have these records.

Formulary – A list of medications that have been approved in advance by the MCHIP.
Sometimes the MCHIP requires that certain criteria or drug therapies be met before
medications in the formulary are approved for a specific patient.

Peer-to-peer –Your prescribing physician is entitled to request a peer-to-peer telephone
conference.  This means your physician can talk directly with your MCHIP’s Medical Director
or their physician designee to discuss matters under appeal.  MCHIP participating providers
should have this telephone number, or it may be in the denial letter you receive.

INFORMATION NEEDED BY YOUR MCHIP
  Pertinent clinical information regarding your
health history and medication history;
 History of any adverse reactions or side
effects you have had to similar medications
(over-the-counter or prescribed), or generic
equivalents that were not effective;
 If the MCHIP requires the prescribing
physician to complete a drug authorization
form, you should make sure this has been
done; and
 If you received a letter of denial for the
medication, ensure that the information
provided to the MCHIP directly addresses the
reasons for denial specified in the letter.

STEPS IN THE APPEAL PROCESS WITH YOUR MCHIP

Step 1:  Contact your prescribing physician and ask him or her to contact the MCHIP’s medical management area or its Medical Director directly and request a peer-to-peer review to discuss the specific reasons why this type of medication is needed for you.
Step 2:  If your physician has already had the peer-to-peer review with the medical management area, and the request for medication continues to be denied, you have the right to appeal this decision in writing to the appropriate department of your MCHIP.  You can find the address to submit appeals in the denial letter, your coverage documents,
or by contacting your MCHIP using the member services telephone number on your ID card.  You should include the bulleted information in your appeal as noted on the previous page.  Follow up with your MCHIP after submitting your request to make sure they have received it.
Step 3:  If after you follow Step 2 your
MCHIP continues to uphold the medication
denial, you should contact the Office of the
Managed Care Ombudsman for assistance.