Managed Care

MA Plans & "Other Healthcare Professional"

  • 1.  MA Plans & "Other Healthcare Professional"

    Posted 06-15-2016 08:33 PM


    I was wondering if any plans who have been through a Program audit by CMS have come across an issue with being cited for failing to ensure that the appropriate healthcare professional reviewed the organization request. I am trying to find out what "Other appropriate health care professional" means....Per:  Ch 13. Section 40.1.1 - Who Must Review an Organization Determination (Rev. 105, Issued: 04-20-12, Effective: 04-20-12, Implementation: 04-20-12),

    "If the Medicare health plan expects to issue a partially or fully adverse medical necessity decision based on the initial review of the request, the organization determination must be reviewed by a physician or other appropriate health care professional with sufficient medical and other expertise, including knowledge of Medicare coverage criteria, before the health plan issues the organization determination."

    If you haven't been audited, I welcome anyone that is willing to help spark a conversation with what your current standards are and how you ensure that this is met.

    Thanks in advance,

    Jeanne Joya
    Atrio Health Plans
    2020 HCCA Managed Care