Respond to appeals from the involved health plan within 24 hours for Expedited Appeals and 7 calendar days for Routine Appeals. Assemble the denial packet response including the cover letter outlining the findings, member’s medical records, a copy of the denied referral request, a copy of the denial letter and rationale for initial decision. Present overturned cases to Medical Director for approval to issue authorization per health plan demand. Log all appeals in to the database for monthly tracking as well as Quarterly Appeals Trending Report to be presented to the Quality Improvement Committee (QIC).
Complete grievance reviews received from the Health Plan, provider or member. Request a response to the involved provider(s) on the same day of receipt or the following day with a specific date. If no response within 3 days of the requested date, nurse will call the provider’s office staff for status of requested items. After researching and reviewing the case, send a response with medical records if applicable, to the involved health plan within the standard timeframe of five (5) to seven (7) days. Response will include cover letter outlining the findings, provider’s response (medical records from provider and facility) and the medical group’s conclusion regarding the stated grievance. All grievances are tracked by monthly logging and Quarterly Grievance Trending Report presented to Quality Improvement Committee (QIC).Conduct investigation and gather evidence required to complete a thorough review of quality of care issues that involve potential harm to a patient or represent serious deficiencies in the performance of duties. Complete all documentation of unexpected events and communicate according to the policies, procedures and chain of command to determine if a Peer Review intervention is necessary. Analysis of other specific cases, providers, or procedures as requested by the Peer Review Chairperson or case managers. Develop mechanisms and review ongoing tracking results of instances of inappropriate or substandard care for the purpose of identifying trends within practice specialties and by individual provider. Request a specific written corrective action plan from providers.