executed amendment agreement between nys attorney general and excellus

7/25/2019 Executed Amendment agreement between NYS Attorney General and Excellus

1/5

AMENDMENT TO ASSURANCE OF DISCONTINUANCE NO. 14-201

Assurance of Discontinuance between the New York State Office of the Attorney

General ( OAG ) and Excellus Health Plan, Inc. ( Excellus ), No. 14-201 (the Assurance ),

dated March 13, 2015, is amended as follows:

1. Auto-Approval for Substance Use Disorder ( SUD ) Treatment

Excellus will auto-approve higher levels of treatment for opioid addiction as follows: 5

days for inpatient SUD detoxification; 14 days for inpatient SUD rehabilitation; and 14 days for

SUD residential treatment. The auto-approval will apply to all New York-licensed facilities. The

new approval process will begin on June 27, 2016. The auto-approval process will be as follows:

a.

Facility contacts Excellus at the time of admission;

b.

Excellus medical intake staff collect information to confirm member enrollment and

eligibility for benefits;

c. Excellus medical intake will confirm that the primary diagnosis is moderate or severe

opioid use disorder (Excellus will accept the providers' conclusion as to diagnosis);

d. Excellus intake staff collect relevant clinical information from the facility (which does

not affect the auto-approval process but is collected for purposes of conducting care

management and clinical review for requests for additional days);

e.

Excellus intake staff transmit clinical information to utilization management staff;

f. Excellus utilization management staff communicates an approval to the facility the

same day if authorization is requested by 2 p.m., and otherwise within 24 hours; and

g.

If the facility requests authorization for additional days beyond the auto-approved

periods noted above, Excellus may conduct a clinical review to determine whether

those additional days will be approved.

Periods of treatment auto-approved by Excellus as set forth above will not be subject to

medical necessity review, including retrospective review.

Excellus will provide notice to providers and members regarding the auto-approval

process, in a form agreed to by the OAG. Excellus will maintain the auto-approval process for at

least one year after the date of execution of this Amendment. If Excellus seeks to modify the

process in any manner after that time, it will provide written notice to the OAG and the parties

will meet and confer regarding the proposed modifications.

Auto-a pprov al for inpatient detoxification, inpatient rehabilitation and residential services will apply to

the extent such services re covered under the mem ber's subscriber contract benefit package.

Substantially all members' benefit packages cover these services.


2/5

To the extent that New York law is more favorable to members and/or providers than

Excellus's auto-approval process, the requirements of applicable New York law will control and

govern.

2.

Switch to LOCADTR (Level of Care for Alcohol and Drug Treatment Referral) Criteria

Excellus will discontinue its use of InterQual medical necessity criteria for review of

SUD services and use the most recent version of LOCADTR issued by the New York State

Office of Alcoholism and Substance Abuse Services for such reviews. The transition to

LOCADTR 3.0 (the current version) will apply to Excellus's commercial and Medicaid Managed

Care lines of business. It will be implemented for Medicaid Managed Care on July 1,2016, and

for commercial by September 1,2016.

3.

Improvements to Excellus's Review Procedures

In conducting reviews for SUD detoxification, SUD inpatient rehabilitation, and SUD

residential treatment following the full transition to LOCADTR (i.e., September 1,2016),

Excellus will implement the following procedures:

a.

Excellus's reviewers will use a questionnaire that asks providers for information

about the m emb er corresponding to: (i) each elem ent of the criteria used by Exc ellus

(for examp le, if the criteria contain a list of factors that m ay satisfy the criterion, the

reviewer m ust ask about each factor); and (ii) each item listed in Assurance Exhibit

A. Excellus's reviewers will document the questions and answers in the member's

case file.

b.

Excellus's reviewers will ask providers how they made their assessment as to the

proper level of care for the member and the criteria they used to make such

assessment. Excellus's reviewers will document the questions and answers in the

member's case file.

c.

Excellus's reviewers will ask providers about, and will consult Excellus's files and all

reasonably accessible medical records for relevant information about the member's

treatment history, as necessary, and will docum ent such efforts, and the information

obtained, in the member's case file.

d.

Subject to receipt of any required HIPAA authorizations, Excellus's reviewers will

attempt to obtain additional information from pro viders, parents and other family

members, as needed, and will document such efforts, and the information obtained, in

the member's case file.


3/5

e. In its quarterly Compliance Administrator Reports issued pursuant to Paragraph 59 of

the Assurance, Excellus will provide written proof to the OAG that it has complied

with these provisions in each review it conducts.

4. Improvements to Excellus's Adverse Determination Letters

Before Excellus issues adverse determ ination letters for inpatient SUD detoxification,

inpatient SUD rehab ilitation, and SUD residential treatmen t, an Excellus Medical Director w ill

review the clinical rationale portion o f the letter for accuracy.

Excellus will continue to implement the following measures set forth in its Plan of

Corrective Action, dated April 8, 2016:

a. Conducting training sessions with discussion and critiques of rationale drafting and

explanation of the Compliance audit process.

b. Retaining an Accreditation Compliance & Quality Administrator specific for

Utilization Management with focused attention on the AOD, with behavioral health

clinical experience.

c. Reviewing monthly audits directly from the Compliance Department with the UM

Supervisor, including direct 1: 1 clinical UM staff review and acknowledgement of

audit results specific to their cases, focused pre-review of individual staff mem bers'

denial letters, review for com pliance and edited, as appropriate, and periodic sharing

with the Corporate Compliance representative for input and collaboration.

d. Conducting UM staff team meetings dedicated to AOD training and compliance in the

following areas:

I) Letter denial content and verbiage.

2)

Review of medical necessity criteria for behavioral health and consistent

application.

3)

Specific deficient audit results with training on the p articular item of deficiency.

4)

Work flow review/ remind ers for consistent application.

e. Multi-disciplinary team meetings including UM staff, operational staff and Medical

Directors to discuss m edical necessity criteria for behavioral health, and its application

to case reviews.

f. Identification, through audit, clinicians who need additional assistance/training in letter

writing, with those team memb ers on 100 up front review of their letters until

sustained improvement is demonstrated.


4/5

g.

Convening Medical Director Team M eetings dedicated to AOD training and

compliance, including the BH Medical Directors including the BH Chief Medical

Officer Corporate Compliance Manager BH UM Supervisor and the UM

Compliance Administrator, to review consistent application of medical necessity

criteria and workflow review.

h.

Assigning one Behavioral Health M edical Director (with BH MD backup) to focus

exclusively on SUD reviews and attain greater compliance and consistency. Other

team members will be included for coverage and training purposes.

i.

The Compliance Administrator and her designees will oversee the activities described

in the plan of correction and report on progress in the quarterly Compliance

Administrator reports.


5/5

AGREED TO BY THE PARTIES:

Dated: Rochester, New York

xcellus Health Plan, Inc.

01 46 0,0

,2016

y:

Stephen Sloan

Executive VP, Chief Adm in. Off., & General

Counsel

Dated: New York, New York

RIC T. SCHNEIDERIVIAN

Attorney General of the State of New York

,2016

LISA LANDAU

Health Care Bureau Chief

By:

MICHAEL D. REISMAN

Assistant Attorney General

Health Care Bureau

executed amendment agreement between nys attorney general and excellus

Documents