Individuals covered under a health benefits plan that uses one or more utilization management (UM) features, has the right to appeal a UM determination that results in a denial, termination or limitation of covered services. Or the covered person may give consent to a health care provider to pursue the UM appeal on the covered person's behalf. A UM determination is a decision made by the carrier about the medical necessity or appropriateness of a particular health care service covered under the terms of the health benefits plan. A UM determination may be made before or after a health care service is rendered, depending upon the terms of the policy.

The second stage of appeal must be initiated within 180 days following receipt of an unfavorable stage one decision. The second stage of appeal is more formal, and usually takes longer. A decision should be rendered for this stage of appeal within 20 business days from the date of receipt of the stage two appeal request.* The appeal will be reviewed by a panel of physicians and/or other health care professionals who have not been involved with the case earlier, but who are knowledgeable about the particular condition and services at issue. The panel, convened by the carrier, shall have access to health care professionals who are part of the carrier's network, or outside consultants in an appropriate specialty, or both. Some carriers offer the covered individual, or health care provider an opportunity to speak with the panel.

If the carrier's UM determination after the stage two appeal does not change, the carrier must give the covered individual (or health care provider, as appropriate) information about how to pursue the appeal externally, and supply the appropriate form (MS Word) (or Medicaid version) to file with the Independent Health Care Appeals Program (IHCAP).

If appropriate, the Department will forward the information to an Independent Utilization Review Organization (IURO), for review. The IURO has 45 calendar days from the date that it receives the appeal request to render a final decision.* Based on the information available to the IURO, it may uphold or reverse the carrier's decision, or it can modify the carrier's decision -- upholding it in part, and reversing it in part. The decision of the IURO is issued in writing, and provided to both the carrier and the covered individual. The decision of the IURO to reverse or modify a carrier's decision is binding upon the carrier and the covered individual, except to the extent that other remedies are available to either party under State or Federal law.

Please note that, on occasion, an individual may be permitted to by-pass a portion of the internal two-stage appeal process, and go directly to the external review. The request to by-pass the first and/or second stage of internal review must be based on the carrier's failure to meet the timeframes for the separate stages of appeal, the carrier's actual waiver of the requirement for the individual to pursue the first or second stage of appeal, or the covered individual and/or provider has applied for an expedited external review at the same time as applying for an expedited internal appeal.

*For emergency and urgent care cases, an admission, availability of care, continued stay and health care services for which the claimant received emergency services but has not been discharged from the facility, the carrier must make its decision on the appeal consistent with the urgency of the case, and in no instance more than 72 hours from the time the appeal is received at stage one, and at stage two. The Department will make every effort to have a decision by an IURO made within 48 hours of receipt of an emergency or urgent care appeal request for external review.