Amy Kile

Standard Operating Procedure (SOP) Initial Determination for Utilization Review Purpose To outline the step-by-step operational process for receiving, reviewing, classifying, and issuing initial determinations for prior authorization requests in accordance with the organization’s Initial Determination Policy and CMS requirements (e.g., 42 CFR §422.566– §422.572). Scope This SOP applies to all Utilization Management (UM) intake staff, clinical reviewers, medical directors, and administrative personnel involved in processing prior authorization requests. Responsibilities • UM Intake Staff: Receive, log, classify, and route requests. • UM Clinical Reviewers: Conduct clinical review using evidence-based criteria. • Medical Directors: Review cases requiring physician-level judgment or adverse determinations. • UM Manager: Oversee compliance with regulatory timeframes and documentation standards. Procedure 1. Receipt and Logging of Requests Accepted Submission Channels • • • • • Fax Provider portal Phone Mail Electronic submission Date of Receipt Record the date and time the request is received. Requests received outside business hours are logged as received on the next business day unless CMS guidance requires otherwise. Intake Documentation UM Intake Staff must: • • • • Verify member eligibility Confirm benefit coverage Log the request in the UM system Attach all submitted clinical documentation 2. Classification of Requests Standard vs. Expedited Classify each request as: • • Standard — routine request Expedited — when delay could jeopardize life, health, or ability to regain maximum function Denial of Expedited Review If expedited criteria are not met: • Reclassify to standard • Provide prompt verbal notice and written confirmation 3. Verification of Representation (AOR) When Required If the request is submitted by a representative: • • Confirm a valid CMS Appointment of Representative (AOR) form is on file If missing or incomplete, pend the request and request documentation 4. Clinical Review Process Standard Review Steps UM Clinical Reviewer must: • • • Review all submitted clinical documentation Apply evidence-based criteria (NCDs, LCDs, InterQual/MCG) Determine whether criteria are met When Criteria Are Met • • Approve the request within reviewer’s scope Document rationale and criteria used When Criteria Are Not Met • • Forward to Medical Director Include summary of findings and criteria not met 5. Medical Director Review Required for: • • • Cases where criteria are not met Cases requiring physician-level judgment All adverse determinations Medical Director Actions • • • • Review clinical documentation Apply clinical judgment and CMS coverage rules Issue approval or adverse determination Document rationale 6. Timeframes for Determinations Standard Requests Must be completed within 14 calendar days of receipt. Expedited Requests Must be completed within 72 hours of receipt. Extensions May extend by up to 14 calendar days when: The enrollee requests it, or • Additional information is needed and delay is in the enrollee’s interest Written extension notice must be issued. • 7. Outreach for Additional Clinical Information UM staff must: • • • Make reasonable attempts to obtain missing clinical information Document all outreach attempts Proceed with determination if timeframes expire 8. Change of Review Priority If new information indicates expedited criteria are met: • • Reclassify to expedited Adjust timeframe accordingly If expedited criteria are not met: • Reclassify to standard • Notify enrollee/provider 9. Withdrawals and Dismissals Withdrawal If enrollee or representative withdraws the request: Document withdrawal • Close the case • Issue written confirmation when required Dismissal • Dismiss when: • • • • • Request is withdrawn Enrollee dies Request is duplicative AOR documentation is not provided Request does not meet definition of an organization determination Dismissal Notice Must include: • • • • Reason for dismissal Regulatory basis Right to request vacating the dismissal Instructions for submitting missing documentation 10. Issuing Determination Notices Fully Favorable Decisions Include: • • • • Approved service(s) Duration, quantity, limitations Effective date Instructions for accessing services Partially Favorable or Adverse Decisions Include: • • • • • • Explanation of decision Specific reason(s) Clinical rationale Appeal rights Instructions for filing reconsideration Required CMS model language Untimely Decisions If timeframes are not met: • • Treat as adverse determination Automatically forward for reconsideration 11. Documentation Requirements UM staff must document: • • • • • • Date/time of receipt Classification (standard/expedited) Outreach attempts Clinical criteria applied Determination rationale Notification details 12. Quality and Compliance Monitoring UM leadership shall: • • • • Monitor timeliness Audit documentation Ensure adherence to CMS requirements Implement corrective actions when needed