Minnesota Department of Health Compliance Monitoring Division Managed Care Systems Section

Final Report Revised January 10, 2007

Medica Health Plans

Quality Assurance Examination For the period

April 1, 2003 – December 31, 2005

Examiners: MaryAnn Fena, J.D.

Elaine Johnson, RN, BS, CPHQ Susan Margot, M.A.

Issue Date: January 10, 2007

Minnesota Department of Health Executive Summary:

The Minnesota Department of Health (MDH) conducted a Quality Assurance Examination of Medica Health Plans to determine whether it is operating in accordance with Minnesota law, applicable federal law, and with the Minnesota Department of Human Services (DHS) contract. Based on the Examination, MDH has found Medica compliant except in the areas outlined in the “Deficiencies” section of this report. The “Recommendations” listed are areas where, although compliant with law, MDH identified improvement opportunities. To address deficiencies, Medica and its delegates must: Ensure that the appeal rights notice attached to enrollee correspondence, including those notices prepared by its delegates, clearly indicates the appropriate Minnesota regulator with which to file complaints. Follow regulatory timelines in making initial utilization management determinations and issuing notices of denial. Revise its policy and practices to extend the timeframe for resolution of standard authorizations for Public Program enrollees by an additional 14 days and include the enrollee’s right to file a grievance in the written notice to the enrollee. Follow the 30-day timeline when resolving appeals and notify in writing the enrollee and the attending health care professional of its determination. Ensure the enrollee receives the written notice of resolution of appeal and that it includes the enrollee’s right to request a State Fair Hearing as well as the State’s Notice of Rights. Provide notification by telephone within one working day to the attending health care professional after making a determination not to certify. Follow timelines as set forth in its policy to address the failure of the provider or enrollee to provide the necessary information for review. In appeals to reverse a determination not to certify for clinical reasons, ensure that a physician in the same or similar specialty as typically manages the medical condition, procedure, or treatment reviews the case. Notify the enrollee of the appeal determination and include in the notification the right to submit the appeal to the external review process and the procedure for initiating, if the determination is not reversed on appeal. Use physician consultants in the appeal process who are board certified.

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To address recommendations, Medica and its delegates should: In its delegation oversight assessment reports, classify those issues that are clear regulatory violations as deficiencies. Develop processes to ensure that the data submitted to MDH for audit purposes is accurate to support the quality examination process. Assure that complaint response letters, including those prepared by delegates, fully and clearly communicate the results of the investigation. Assure that complaint response letters including those prepared by delegates more clearly identify the appropriate agency (MDH or Department of Commerce) to which enrollees may file a complaint. Assure that resolution notice letters do not contain potentially misleading information about member rights. Include in its utilization management policy/procedure the expected regulatory timelines staff needs to follow for the entire determination process. This report including these deficiencies and recommendations is approved and adopted by the Minnesota Commissioner of Health pursuant to authority in Minnesota Statutes, chapter 62D. __________________________________________ _______________________ Darcy Miner, Director Date Compliance Monitoring Division

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I. Introduction .............................................................................................................................................. 5 II. Quality Program Administration ............................................................................................................. 6 Minnesota Rules, Part 4685.1110. Program ................................................................................................ 6 Minnesota Rules, Part 4685.1115. Activities............................................................................................... 7 Minnesota Rules, Part 4685.1120. Quality Evaluation Steps ...................................................................... 8 Minnesota Rules, Part 4685.1125. Focused Study Steps ............................................................................. 8 Minnesota Rules, Part 4685.1130. Filed Written Plan and Work Plan........................................................ 8 III. Complaints and Grievance Systems................................................................................................. 8 Commercial Products -- Complaint and Appeal File Review....................................................................... 8 Minnesota Statutes, Section 62Q.69. Complaint Resolution ....................................................................... 9 Minnesota Statutes, Section 62Q.70. Appeal of the Complaint Decision.................................................... 9 Minnesota Statutes, Section 62Q.71. Notice to Enrollees ........................................................................... 9 Minnesota Rules, Part 4685.1900. Records of Complaints ......................................................................... 9 Minnesota Statutes, Section 62Q.73. External Review of Adverse Determinations ................................. 10 Section 8.1. - §438.402 General Requirements................................................................................... 10 Section 8.2. - §438.404 DTR Notice of Action to Enrollees................................................................ 10 Section 8.3. - §438.408 Internal Grievance Process Requirements ..................................................... 11 Section 8.4. - §438.408 Internal Appeals Process Requirements........................................................ 11 Section 8.5. - §438.416 Maintenance of Grievance and Appeal Records............................................ 13 Section 8.7. - §438.408(f) State Fair Hearings .................................................................................... 13 Minnesota Rules, Part 4685.1900. Records of Complaints ....................................................................... 13 IV. Access and Availability ....................................................................................................................... 13 Minnesota Statutes, Section 62D.124. Geographic Accessibility.............................................................. 13 Minnesota Rules, Part 4685.1010. Availability and Accessibility............................................................. 13 Minnesota Statutes, Section 62Q.55. Emergency Services........................................................................ 13 Minnesota Statutes, Section 62Q.121. Licensure of Medical Directors .................................................... 14 Minnesota Statutes, Section 62Q.14. Open Access to Family Planning.................................................... 14 Minnesota Statutes, Section 62A.15. General Services (Equal Access to Chiropractic, Optometric, and Nursing Services)........................................................................................................................................ 14 Minnesota Statutes, Section 62Q.52. Direct Access to Obstetric and Gynecologic Services.................... 14 Minnesota Statutes, 62Q.527. Coverage of Nonformulary Drugs for Mental Illness and Emotional Disturbance ................................................................................................................................................. 14 Minnesota Statutes, Section 62Q.535. Coverage for Court-Ordered Mental Health Services .................. 14 Minnesota Statutes, Section 62Q.56. Continuity of Care .......................................................................... 14 Minnesota Statutes, Section 62Q.58. Access to Specialty Care ................................................................ 15 V. Utilization Review ................................................................................................................................ 15 Utilization Review ...................................................................................................................................... 15 Minnesota Statutes, Section 62M.04. Standards for Utilization Review Performance.............................. 15 Minnesota Statutes, Section 62M.05. Procedures for Review Determination ........................................... 15 Minnesota Statutes, Section 62M.06. Appeals of Determinations not to Certify ...................................... 17 Minnesota Statutes, Section 62M.08. Confidentiality ............................................................................... 18 Minnesota Statutes, Section 62M.09. Staff and Program Qualifications................................................... 18 Minnesota Statutes, Section 62M.10. Accessibility and on-site Review Procedures ................................ 18 Minnesota Statutes, Section 62M.11. Complaints to Commerce or Health............................................... 18 Minnesota Statutes, Section 62M.12. Prohibition on Inappropriate Incentives......................................... 18 Minnesota Statutes, Section 62D.12. Prohibited Practices ........................................................................ 18 Minnesota Statutes, Section 62A.25. Reconstructive Surgery................................................................... 19 VI. Participating Entity Site Visits....................................................................................................... 19 VII. Recommendations.......................................................................................................................... 19 VIII. Deficiencies...................................................................................................................................... 20

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I. Introduction A. History: Medica Health Plans is a not-for-profit, open access health maintenance

organization (HMO) that provides coverage for health services in the state of Minnesota. Medica was organized in 1974 as Physicians Health Plan of Greater Minneapolis. Over the years, Medica experienced a number of mergers. The company’s most recent restructuring occurred in 2001, at which time Medica separated from Allina Health Systems. Medica contracts with United Healthcare Group to provide certain administrative services for the organization.

B. Membership: Medica self-reported enrollment as of January 2006 consisted of the

following:

Enrollment Fully insured Commercial 125238 Prepaid Medical Assistance Program 92403 MinnesotaCare 29546 General Assistance Medical Care 8488 Medicare Advantage – Private FFS 880 Medicare Select Solution - Supplement 2972 Minnesota Senior Health Options 3242 Total 262769

C. Onsite Examination Dates: May 15, 2006 through May 25, 2006 D. Examination Period: April 1, 2003 through December 31, 2005

E. National Committee for Quality Assurance (NCQA): Medica is accredited by NCQA

based on 2004/2005 standards. The Minnesota Department of Health (MDH) evaluated and used results of the NCQA review in one of three ways.

• If NCQA standards do not exist or are not as stringent as Minnesota law, the review results will not be used for evaluation [no NCQA box].

• If the NCQA review was the same or more stringent than Minnesota law and Medica was accredited with 100% of the possible points, the NCQA review result was accepted as meeting Minnesota requirements [ NCQA] unless evidence existed indicating further investigation was warranted [ NCQA].

• If the NCQA standard was the same or more stringent than Minnesota law, but the review resulted in less than 100% of the possible points on NCQA’s score sheet or as an identified opportunity for improvement, MDH conducted its own examination.

F. Sampling Methodology: Due to the small sample sizes and the methodology used for sample selection for the quality assurance examination, the results cannot be extrapolated as an overall deficiency rate for the health plan.

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G. Performance Standard: For each instance of non-compliance with applicable law or rule identified during the course of the quality assurance examination, which covers a three-year audit period, the health plan is cited with a deficiency.

II. Quality Program Administration

Minnesota Rules, Part 4685.1110. Program Subp. 1. Written Quality Assurance Plan yes no NCQA Subp. 2. Documentation of Responsibility yes no NCQA Subp. 3. Appointed Entity yes no NCQA Subp. 4. Physician Participation yes no NCQA Subp. 5. Staff Resources yes no NCQA Subp. 6. Delegated Activities yes no NCQA1

Subp. 7. Information System yes no NCQA Subp. 8. Program Evaluation yes no NCQA Subp. 9. Complaints yes no Subp. 10. Utilization Review yes no Subp. 11. Provider Selection and Credentialing yes no NCQA Subp. 12. Qualifications yes no NCQA Subp. 13. Medical Records yes no NCQA Subp. 6. Minnesota Rules, part 4685.1110, subpart 6, states the HMO may delegate the performance of activities to other entities. The delegated functions of Quality and Credentialing were reviewed by NCQA and accepted by MDH. Medica delegates as follows:

Delta Dental Plan of Minnesota (provides services for Medicaid and MSHO populations only) – Utilization Review, complaints/grievances, first level appeals, customer service, network management, claims, credentialing/recredentialing Evercare – Utilization Review Chiropractic Care of Minnesota, Inc./ACN Group – Utilization Review, complaints/grievances, first level appeals, customer service, network management, credentialing/recredentialing HealthPartners - Credentialing/recredentialing Health Service Management, Inc. (HSM) (provides chiropractic care to MSHO population only) – Utilization Review, grievances, first level appeals, customer service, network management, credentialing/recredentialing Mayo Clinic, Rochester - Credentialing/recredentialing Olmstead Medical Center - Credentialing/recredentialing United Behavioral Health (UBH) – Utilization review, quality improvement, complaints/grievances, first level appeals, customer service, network management, credentialing/recredentialing.

1 NCQA delegation standards are equivalent to Minnesota law for credentialing and quality improvement functions only

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Review of delegation agreements, oversight documents, meeting minutes, audit reports, corrective action plans and staff interviews indicated thorough and comprehensive review and reporting processes that ensured the delegated entities are adequately performing the functions outlined in the contracts/delegation agreements. Medica identifies areas of improvement by designating them as a deficiency, recommendation or suggestion. According to the Medica Delegation Manual (March 2006), a deficiency is considered to be any business practice or program document that conflicts with, or does not support, a measurable regulatory or accreditation requirement. In reviewing annual site assessment reports, MDH noted that Medica classified issues as recommendations or suggestions that in two instances2 were clear regulatory violations. (Recommendation #1) Subp. 7. Minnesota Rules, part 4685.1110, subpart 7, mandates the data collection and reporting system must support the information needs of the quality assurance program activities. When submitting data to MDH, Medica did not initially distinguish enrollees in State Public Programs and fully-insured programs from Medica Insurance Company (MIC) enrollees (monitored by Department of Commerce) resulting in considerable rework to develop accurate and adequate file samples. During file review, it was noted that optional clinical second level appeals and MDH appeals were included in with clinical first level appeals, commercial inquiries were included in with complaint data, and MIC files continued to be in with the sample files. Medica should develop processes to ensure that the data submitted to MDH for audit purposes is accurate to support the quality assurance examination process. (Recommendation #2) Subp. 9. Minnesota Rules, part 4685.1110, subpart 9, refers to Grievances and Complaints related to Quality of Care:

Quality of Care File Review

File Source Complaints (Commercial)

Grievances (Public Programs)

Medica 9 8 UBH 6 6 ACN 1 1 Delta 5 Totals 16 20

Based on file review and staff interviews, Medica and its delegates conduct a thorough investigation of grievances and complaints related to quality of care. Minnesota Rules, Part 4685.1115. Activities Subp. 1. Ongoing Quality Evaluation yes no NCQA Subp. 2. Scope yes no NCQA

2 Refer to Deficiencies #1 and #5

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Minnesota Rules, Part 4685.1120. Quality Evaluation Steps Subp. 1. Problem Identification yes no NCQA Subp. 2. Problem Selection yes no NCQA Subp. 3. Corrective Action yes no NCQA Subp. 4. Evaluation of Corrective Action yes no NCQA

Minnesota Rules, Part 4685.1125. Focused Study Steps Subp. 1. Focused Studies yes no NCQA Subp. 2. Topic Identification and Selection yes no NCQA Subp. 3. Study yes no NCQA Subp. 4. Corrective Action yes no NCQA Subp. 5. Other Studies yes no NCQA

Minnesota Rules, Part 4685.1130. Filed Written Plan and Work Plan Subp. 1. Written Plan yes no Subp. 2. Work Plan yes no NCQA Medica filed the Medica 2005 Quality Improvement Program Description with MDH in May 2005.

III. Complaints and Grievance Systems

Commercial Products -- Complaint and Appeal File Review File Source Complaints

(Included oral complaints under MS §62Q.05 and inquiries)

Non-Clinical Appeals (Included oral complaints not resolved by Member Services, written complaints and enrollee appeals of UM determinations under MS §62M.05)

2nd Level of Appeals (Included appeals under MS §62Q.06 and optional internal appeals of UM determinations)

Medica 67 30 29 Delta Dental 12 Included in Medica Data ACN 11 6 UBH 10 10 Totals 100 46 29

Complaints related to quality of care are addressed in the section of this report entitled Quality Program Administration, Minnesota Rules, part 4685.1110, subpart 9.

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Minnesota Statutes, Section 62Q.69. Complaint Resolution Subd. 1. Establishment yes no Subd. 2. Procedures for filing a complaint yes no Subd. 3(a) Notification of complaint decisions within 30 days

yes no Subd. 3(b) Notification of right to appeal yes no Subd. 3(c) Notification of right to submit complaint for investigation yes no Subd. 3(a). MDH found two UBH complaint files in which the response letter did not fully and clearly communicate the results of the investigation. Documentation from UBH indicated that in two cases the issue was investigated and resolved, but the letters did not fully explain the outcome and the action taken by UBH in resolving the issue. (Recommendation #3) Subd. 3(c). Minnesota Statutes, section 62Q.69, subdivision 3(c), requires that the notice of complaint resolution must inform the enrollee of the right to submit the complaint at any time to the commissioner of either Health or Commerce for investigation and the toll-free telephone number of the appropriate commissioner. In six files (all from UBH) where the letter acknowledging receipt of the complaint and/or the notice of complaint resolution included the telephone numbers of both MDH and the Department of Commerce without clearly identifying which was the appropriate regulatory agency. (Recommendation #4) Five of the six files also referred the enrollee to the North Dakota and Wisconsin regulatory agencies. In its 2004 annual delegate site audit, Medica noted the reference to North Dakota and Wisconsin and suggested3 that UBH should edit the template as appropriate. UBH noted in its corrective action plan that it revised its response letters. However, one of the five files identified above was dated July 2005. Finally, in one file ACN referred the enrollee to the Minnesota Department of Commerce. (Deficiency #1)

Minnesota Statutes, Section 62Q.70. Appeal of the Complaint Decision Subd. 1. Establishment yes no Subd. 2. Procedures for Filing an Appeal yes no Subd. 3. Notification of Appeal Decisions yes no

Minnesota Statutes, Section 62Q.71. Notice to Enrollees yes no

Minnesota Rules, Part 4685.1900. Records of Complaints Subp. 1. Record Requirements yes no

3 See Recommendation #1

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Subp. 2. Log of Complaints yes no

Minnesota Statutes, Section 62Q.73. External Review of Adverse Determinations Subd. 2. Exception yes no Subd. 3. Right to external review yes no Grievance and Appeal System for State Public Programs MDH examined Medica’s public program grievance system for compliance with the federal BBA law (42 CFR 438, subpart F) and the DHS 2005 Model Contract, Article 8. MDH reviewed a total of 154 files related to the grievance and appeal system for enrollees of Public Programs:

Grievance and Appeal File Review

File Source Grievances Clinical Appeals

Non-clinical Appeals

State Fair Hearings

Medica 12 32 16 3 UBH 10 11 12 ACN 8 12 5 Delta 12 12 8 Totals 43 67 41 3

Grievances related to quality of care are addressed in the section of this report entitled Quality Program Administration, Minnesota Rules, part 4685.1110, subpart 9.

Section 8.1. - §438.402 General Requirements Sec. 8.1.1. Components of Grievance System yes no Sec. 8.1.2. Timeframes for Disposition yes no

Section 8.2. - §438.404 DTR Notice of Action to Enrollees Sec. 8.2.1. General requirements yes no Sec. 8.2.2. - §438.404 (c) Timing of DTR Notice

A. §438.404 (c)(1) Previously Authorized Services yes no B. §438.404 (c)(2) Denials of Payment yes no C. §438.210 (d)(1) Standard Authorizations yes no D. §438.210 (d)(1) Extensions of Time yes no E. §438.210 (d)(1) Delay in Authorizations yes no F. §438.210 (d)(2) Expedited Authorizations yes no

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Sec. 8.2.3. - §438.420 Continuation of Benefits Pending Decision yes no 42 CFR 438.210(d)(1), (DHS contract 8.2.2.C. and E.), states for standard authorization decisions, the MCO must provide notice as expeditiously as the enrollee’s health condition requires, not to exceed ten business days. If the authorization decision is not reached within the specified timeframe, the MCO must provide a notice of denial on the date the timeframe expires. Sixteen out of the 97 files representing Public Programs exceeded the state established timelines (and did not request an extension) and the notice of denial was sent after the timeframe expired. (Deficiency #2)4 42 CFR 438.210(d)(1), (DHS contract 8.2.2D.), states that the MCO may extend the timeframe by an additional 14 days for resolution of a standard authorization if the enrollee or provider requests the extension, or if the MCO justifies a need for additional information and the extension is in the enrollee’s interest. The MCO must provide written notice to the enrollee of the reason for the extension and the enrollee’s right to file a grievance if he or she disagrees with the decision. In seven public program files where an extension was requested, Medica extended the timeframe by an additional 45 days, rather than the required 14, and the written notice to the enrollee did not include the enrollee’s right to file a grievance. Review of Medica’s utilization policy and staff interviews verified non-compliance with the 14-day extension and the inclusion of the enrollee’s right to file a grievance in the written notice. (Deficiency #3)

Section 8.3. - §438.408 Internal Grievance Process Requirements Sec. 8.3.1. - §438.402(b) Filing Requirements yes no (also see §438.402 (c)(ii)) Sec. 8.3.2. - §438.408(b) Timeframe for Resolution of Grievances yes no Sec. 8.3.3. - §438.408(c) Timeframe for Extension of Resolution of Grievances yes no Section 8.3.4. - §438.406 Handling of Grievances

A. §438.406(a)(2) Written Acknowledgement yes no B. §438.416 Log of Grievances yes no C. §438.402(b)(3) Oral or Written Grievances yes no D. §438.406(a)(1) Reasonable Assistance yes no E. §438.406(a)(3)(i) Individual Making Decision yes no F. §438.406(a)(3)(ii) Appropriate Clinical Expertise

[See Minnesota Statutes, section 62M.06, subd. 3(f)]

Section 8.4. - §438.408 Internal Appeals Process Requirements Sec. 8.4.1. - §438.408(b)(1) Filing Requirements yes no Sec. 8.4.2. - §438.408(b)(2) Timeframe for Resolution of Standard Appeals

yes no Sec. 8.4.3 - §438.408(b)(3) Timeframe for Resolution of Expedited Appeals

4 Also see Minnesota Statutes, section 62M.05, subdivision 3a(a)

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yes no A. §438.408(d)(2)(ii) Expeditious Resolution and oral notice

yes no B. §438.410(b) Punitive Action Prohibited yes no C. §438.410(c) Denial of Request for Expedited Appeal

yes no Sec. 8.4.4. - §438.408(c) Timeframe for Extension of Resolution of Appeals

yes no Sec. 8.4.5. - §438.406 Handling of Appeals

A. §438.406(b)(1) Oral Inquiries yes no B. §438.406(a)(2) Written Acknowledgement yes no C. §438.406(a)(1) Reasonable Assistance yes no D. §438.406(a)(3)(i) Individual Making Decision yes no E. §438.406(a)(3)(ii) Appropriate Clinical Expertise

[See Minnesota Statutes, section 62M.06, subd. 3(f)] F. §438.406(b)(2) Opportunity to Present Evidence yes no G. §438.406(b)(3) Opportunity to Examine the Case File

yes no H. §438.406(b)(4) Parties to the Appeal yes no

Sec. 8.4.7. - §438.408(d)(2) Notice of Resolution of Appeals yes no Sec. 8.4.8. - §438.424 Reversed Appeal Resolutions yes no Sec. 8.4.9. - §438.420(d) Upheld Appeal Resolutions yes no 42 CFR 438.408(b)(2), (DHS contract 8.4.2), states the plan must resolve appeals no later than 30 days after receipt. There were four files in which the plan exceeded the 30-day timeline (and did not request an extension.). (Deficiency #4)5 42 CFR 438.408(d)(2), (DHS contract 8.4.7), states the written notice of resolution must include the enrollee’s right to request a State Fair Hearing and how to do so, and it must also include the State’s Notice of Rights. There were five files in which the resolution notice letter included the following statement: “If you are not completely satisfied with [the Plan’s] decision, you may request a second level appeal.” Although the State’s Notice of Rights statement was enclosed with the resolution letter, the resolution letters themselves did not include a statement about the enrollee’s right to request a State Fair Hearing. Under these circumstances, omitting the right to State Fair Hearing in the resolution letter could be misleading to the enrollee. (Recommendation #5) Also, there were seven files where the enrollee did not receive a written notice of resolution of appeal and did not receive either a notice of the right to request a State Fair Hearing or the State’s Notice of Rights. (Deficiency #5) Medica staff indicated during interviews that this was addressed during an annual site visit. Review of the annual oversight document entitled Delegated Utilization Management: 2005 Site Assessment Report ACNGroup/ChiroCare of Minnesota dated July 2005, showed this was cited as a recommendation only and was not specifically addressed in the corrective action plan.6 5 Also see Utilization Review, Minnesota Statutes, section 62M.06, subdivision 3(a) 6 Refer to Recommendation #1

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Section 8.5. - §438.416 Maintenance of Grievance and Appeal Records yes no

Section 8.7. - §438.408(f) State Fair Hearings Sec. 8.7.2. - §438.408(f) Standard Hearing Decisions yes no Sec. 8.7.5. - §438.420 Continuation of Benefits Pending Resolution of State Fair Hearing yes no Sec. 8.7.6. - §438.424 Compliance with State Fair Hearing Resolution

yes no Section 8.7.7. - §438.408 (f)(2) Representation of MCO Determinations yes no

Minnesota Rules, Part 4685.1900. Records of Complaints Subp. 1. Record Requirements yes no Subp. 2. Log of Complaints §438.416 (a) -- yes no

IV. Access and Availability

Minnesota Statutes, Section 62D.124. Geographic Accessibility Subd. 1. Primary Care; Mental Health Services; General Hospital Services yes no Subd. 2. Other Health Services yes no Subd. 3. Exception yes no

Minnesota Rules, Part 4685.1010. Availability and Accessibility Subp. 2. Basic Services yes no Subp. 5. Coordination of Care yes no Subp. 6. Timely Access to Health Care Services yes no Minnesota Statutes, Section 62Q.55. Emergency Services

yes no

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Minnesota Statutes, Section 62Q.121. Licensure of Medical Directors yes no

Minnesota Statutes, Section 62Q.14. Open Access to Family Planning. yes no

Minnesota Statutes, Section 62A.15. General Services (Equal Access to Chiropractic, Optometric, and Nursing Services) Subd. 2. Chiropractic Services yes no Subd. 3. Optometric Services yes no Subd. 3a. Nursing Services yes no

Minnesota Statutes, Section 62Q.52. Direct Access to Obstetric and Gynecologic Services yes no

Minnesota Statutes, 62Q.527. Coverage of Nonformulary Drugs for Mental Illness and Emotional Disturbance Subd. 2. Required Coverage for Anti-psychotic Drugs yes no Subd. 3. Continuing Care yes no Subd. 4. Exception to formulary yes no

Minnesota Statutes, Section 62Q.535. Coverage for Court-Ordered Mental Health Services Subd. 1. Mental health services yes no Subd. 2. Coverage required yes no

Minnesota Statutes, Section 62Q.56. Continuity of Care Subd. 1. Change in health care provider; general notification

yes no Subd. 1a. Change in health care provider; termination not for cause yes no Subd. 1b. Change in health care provider; termination for cause. yes no Subd. 2. Change in health plans yes no Subd. 2a. Limitations yes no

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Subd. 2b. Request for authorization yes no Subd. 3. Disclosures yes no

Minnesota Statutes, Section 62Q.58. Access to Specialty Care Subd. 1. Standing Referral yes no Subd. 1a. Mandatory Standing Referral yes no Subd. 2. Coordination of Services yes no Subd. 3. Disclosure yes no Subd. 4 Referral yes no

V. Utilization Review MDH reviewed a total of 214 utilization review files:

Utilization Review File Source UM Commercial UM Public

Programs (also see Sec. 8.2.2. -

§438.404 (c)

Commercial Clinical Appeals*

Medica 30 30 30 ACN 12 10 9 UBH 11 15 10 MedImpact 15 15 Delta Dental 12 EverCare 15 Totals 68 97 49

*Utilization management appeal files for public program enrollees were reviewed as appeal files under the Public Program grievance system, Section 8.4 - §438.408.

Minnesota Statutes, Section 62M.04. Standards for Utilization Review Performance Subd. 1. Responsibility on Obtaining Certification yes no Subd. 2. Information upon which Utilization Review is Conducted yes no Subd. 3. Data Elements yes no Subd. 4. Additional Information yes no Subd. 5. Sharing of Information yes no

Minnesota Statutes, Section 62M.05. Procedures for Review Determination Subd. 1. Written Procedures yes no Subd. 2. Concurrent Review yes no NCQA

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Subd. 3. Notification of Determinations yes no Subd. 3a. Standard Review Determination (a) Intial determination to certify (10 business days) yes no (b) Initial determination to certify (telephone notification) yes no (c) Initial determination not to certify yes no

(d) Initial determination not to certify (notice of rights to internal appeal) yes no NCQA

Subd. 3b. Expedited Review Determination yes no NCQA Subd. 4. Failure to Provide Necessary Information yes no Subd. 5. Notifications to Claims Administrator yes no Subd. 1. Minnesota Statutes, section 62M.05, subdivision 1, states the HMO must have written procedures to ensure that reviews are conducted in accordance with regulatory requirements of 62M.05. The policy/procedure Case Intake/Case Assignment and Medical Necessity Reviews: Non-Urgent Preservice/Standard Urgent/Expedited, Postservice/Retro, specifies that Medica follows the most restrictive regulation, which is making the notification of the determination within two business days of receipt of the request and all information. It may be helpful to include in the policy/procedure the expected regulatory timelines staff needs to follow for the entire determination process. (Recommendation #6) Subd. 3a(a). Minnesota Statutes, section 62M.05, subdivision 3a(a), states an initial determination on all requests for utilization review must be communicated to the provider and enrollee within ten business days provided that all information reasonably necessary to make a determination has been made available. Six files out of the total 68 commercial UM files reviewed were outside of the timelines. A total of 22 files (both Public Program and commercial) were outside of the regulatory timelines. (Deficiency #2)7 Subd. 3a(c). Minnesota Statutes, section 62M.05, subdivision 3a(c), states when an initial determination is made not to certify, notification must be provided by telephone within one working day after making the determination to the attending health care professional. Eighteen files, including both commercial and public program, did not document that notification of the denial was communicated within one working day to the attending health care provider. Ten of those files were from delegates where this was recognized by Medica and was addressed in a corrective action plan. (Deficiency #6) Subd. 4. Minnesota Statutes, section 62M.05, subdivision 4, states the HMO must have written procedures to address the failure of the provider or enrollee to provide the necessary information for review. Medica’s policy entitled Case Intake/Case Assignment and Medical Necessity Reviews: Non-Urgent Preservice/Standard Urgent/Expedited, Postservice/Retro, states that if there is lack of information to process the review, the member or member’s authorized representative must be given an additional 45 days in addition to the standard authorization timeline. In three files where the lack of information standard was applied, Medica exceeded the timeline as set forth in the policy. (Deficiency #7) 7 Also see Grievance and Appeal, Section 8.2.2. C and E, §438.210(d)(1)

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Minnesota Statutes, Section 62M.06. Appeals of Determinations not to Certify Subd. 1. Procedures for Appeal yes no Subd. 2. Expedited Appeal yes no Subd. 3. Standard Appeal (a) Appeal resolution notice timeline yes no (b) Documentation requirements yes no

(c) Review by a different physician yes no NCQA (d) Time limit in which to appeal yes no (e) Unsuccessful appeal to reverse determination yes no NCQA (f) Same or similar specialty review yes no NCQA (g) Notice of rights to External Review yes no NCQA

Subd. 4. Notifications to Claims Administrator yes no Subd. 3(a). Minnesota Statutes, section 62M.06, subdivision 3(a), states that the HMO must notify in writing the enrollee and the attending health care professional of its determination on the appeal within 30 days upon receipt. Four commercial appeal files exceeded the 30-day timeline. A total of eight files (both Public Program and commercial) were outside of the regulatory 30-day timeline8. Additionally, five appeal files (ACN) did not contain notification to the enrollee of its appeal determination. Medica indicated this issue was addressed with its delegate in the annual oversight assessment done for 20049, however the two files from 2005 continued to omit the required enrollee notification of the determination. (Deficiency #4)8

Subd. 3(f). Minnesota Statutes, section 62M.06, subdivision 3(f), states that in appeals to reverse a determination not to certify for clinical reasons, the HMO must ensure that a physician in the same or similar specialty as typically manages the medical condition, procedure, or treatment reviews the case. Medica’s policy entitled Minnesota HMO and State Public Program First Level Clinical Appeals Same or Similar Specialty Physician Review states that in the event the Medical Director agrees with the initial denial, the appeal (first level) will be prepared for external same specialty review if it is on the Same or Similar Specialty Review List (included in the policy). Five appeal files were not sent for specialty review according to Medica’s policy out of a total of 13 cases from 2005. (Deficiency #8) Subd. 3(g). Minnesota Statutes, section 62M.06, subdivision 3(g), states that if the initial determination is not reversed on appeal, the HMO must include in its notification the right to submit the appeal to the external review process and the procedure for initiating. There were four files where the denial was upheld or modified on appeal and the enrollee was not sent a notification of the determination (see subdivision 3(a) above) thus did not receive the right to submit the appeal to the external review process or the procedure for doing so. There was one file where the enrollee was sent a notification that the denial was modified on appeal, but the notification did not include the right to submit the appeal to the external review process and the procedure for doing so. (Deficiency #9) 8 Also see Grievance and Appeal System, §438.408(b)(2) (DHS contract 8.4.2) 9 Refer to Recommendation #1 and Deficiency #5

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Minnesota Statutes, Section 62M.08. Confidentiality yes no NCQA

Minnesota Statutes, Section 62M.09. Staff and Program Qualifications Subd. 1. Staff Criteria yes no NCQA Subd. 2. Licensure Requirement yes no NCQA Subd. 3. Physician Reviewer Involvement yes no NCQA Subd. 3a. Mental Health and Substance Abuse Review yes no Subd. 4. Dentist Plan Reviews yes no NCQA Subd. 4a. Chiropractic Reviews yes no NCQA Subd. 5. Written Clinical Criteria yes no NCQA Subd. 6. Physician Consultants yes no NCQA Subd. 7. Training for Program Staff yes no NCQA Subd. 8. Quality Assessment Program yes no NCQA Subd. 6. Minnesota Statutes, section 62M.09, subdivision 6, states that physician consultants used in the appeal process must be board certified. In nine appeal files, (five commercial, four Public Program), the cases were reviewed by a physician that was not board certified. (Deficiency #10)

Minnesota Statutes, Section 62M.10. Accessibility and on-site Review Procedures Subd. 1. Toll-free Number yes no NCQA Subd. 2. Reviews during Normal Business Hours yes no NCQA Subd. 7. Availability of Criteria yes no

Minnesota Statutes, Section 62M.11. Complaints to Commerce or Health yes no

Minnesota Statutes, Section 62M.12. Prohibition on Inappropriate Incentives yes no NCQA

Minnesota Statutes, Section 62D.12. Prohibited Practices Subd. 19. Coverage of service yes no

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Minnesota Statutes, Section 62A.25. Reconstructive Surgery Subd. 2. Required coverage yes no VI. Participating Entity Site Visits Three participating entity site visits took place on June 5 and June 7, 2006 as a part of the Medica Quality Assurance Examination, which included Delta Dental Plan of Minnesota, Chiropractic Care of Minnesota, Inc./ACN Group, and United Behavioral Health (UBH).

Delta Dental Plan of Minnesota (Delta) provides dental utilization review, grievances, first level appeals, customer service, network management, claims and credentialing/recredentialing functions for Medica. Medica delegates these functions to Delta Dental for the Medicaid and MSHO populations only, since Medica and Delta jointly own a commercial dental product. Chiropractic Care of Minnesota, Inc./ACN Group (ACN) provides the functions of chiropractic utilization review, complaints/grievances, first level appeals, customer service, and network management for Medica’s Medicaid and commercial populations. Chiropractic services for MSHO enrollees are delegated to another vendor. United Behavioral Health (UBH) provides and coordinates mental health/substance abuse services for Medica for the functions of utilization review, complaints/grievances, appeals, customer service, and network management. UBH attends Medica’s Delegation Committee every other month.

Discussions with the above delegates consisted of general delegation oversight activities performed by Medica and specific questions related to issues resulting from the delegates’ files to clarify policies and/or processes. All three delegates reported a positive, collaborative working relationship with Medica in the performance and oversight of the delegated functions. VII. Recommendations 1. To better comply with Minnesota Rules, part 4685.1110, subpart 6, Medica, in its delegation

oversight assessment reports, should classify those issues that that are clear regulatory violations as deficiencies.

2. To better comply with Minnesota Rules, part 4685.1110, subpart 7, Medica should develop

processes to ensure that the data submitted to MDH for audit purposes is accurate to support the quality assurance examination process.

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3. To better comply with Minnesota Statutes, section 62Q.69, subdivision 3(a), Medica should assure that complaint response letters, including those prepared by delegates, fully and clearly communicate the results of the investigation.

4. To better comply with Minnesota Statutes, section 62Q.69, subdivision 3(c), Medica should

assure that complaint response letters, including those prepared by delegates, more clearly identify the appropriate regulatory agency (MDH or Department of Commerce) to which enrollees may file a complaint.

5. To better comply with 42 CFR 438.408(g), (DHS contract 8.4.7.), Medica should not use

potentially misleading language in its resolution notice letters regarding the members’ rights. 6. To better comply with Minnesota statutes, section 62M.05, subdivision 1, Medica should

include in the utilization management policy/procedure the expected regulatory timelines staff needs to follow for the entire determination process.

VIII. Deficiencies 1. To comply with Minnesota Statutes, section 62Q.69, subdivision 3(c), Medica must ensure

that the appeal rights notice attached to enrollee correspondence, including those notices prepared by its delegates, clearly indicates the appropriate Minnesota regulator with which to file complaints.

2. To comply with 42 CFR 438.210 (d)(1), (DHS contract 8.2.2.C and E.), and Minnesota

Statutes, section 62M.05, subdivision 3a(a), Medica and its delegates must follow regulatory timelines in making its initial utilization management determinations and issuing notices of denial.

3. To comply with 42 CFR 438.210(d)(1), (DHS contract 8.2.2.D.), Medica must revise its

policy and practices to extend the timeframe for resolution of standard authorizations for Public Program enrollees by an additional 14 days and include the enrollee’s right to file a grievance in the written notice to the enrollee.

4. To comply with 42 CFR 438.408(b)(2), (DHS contract 8.4.2.), Medica and its delegates must

follow the 30-day timeline when resolving standard Public Program appeals. To comply with Minnesota Statutes, section 62M.06, subdivision 3(a), Medica and its delegates must notify in writing the enrollee and the attending health care professional of its determination on the appeal within 30 days upon receipt.

5. To comply with 42 CFR 438.408(d)(2), (DHS contract 8.4.7), Medica and its delegates must

ensure the enrollee receives the written notice of resolution of appeal and that it includes the enrollee’s right to request a State Fair Hearing as well as the State’s Notice of Rights.

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6. To comply with Minnesota Statutes, section 62M.05, subdivision 3a(c), Medica and its delegates must provide notification by telephone (or fax) within one working day to the attending health care professional after making an initial determination not to certify.

7. To comply with Minnesota Statutes, section 62M.05, subdivision 4, Medica must follow the

timelines as set forth in its policy to address the failure of the provider or enrollee to provide the necessary information for review.

8. To comply with Minnesota Statutes, section 62M.06, subdivision 3(f), Medica must, in

appeals to reverse a determination not to certify for clinical reasons, ensure that a physician in the same or similar specialty as typically manages the medical condition, procedure, or treatment reviews the case.

9. To comply with Minnesota Statutes, section 62M.06, subdivision 3(g), Medica and its

delegates must notify the enrollee of the appeal determination and include in the notification the right to submit the appeal to the external review process and the procedure for initiating, if the initial determination is not reversed on appeal.

10. To comply with Minnesota Statutes, section 62M.09, subdivision 6, Medica must use

physician consultants in the appeal process who are board certified.

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