Verify PA stance and watch alternate terminology in COCs

Company materials (Data Call template) indicate that no prior authorization (PA) is required for any Med/Surg or MH/SUD services; however, consumer-facing Certificates of Coverage use alternative terminology ("Medical Management Techniques" / "Predetermination") rather than the term "prior authorization," and the list of services subject to CR and RR could not be reconciled to the COCs. Providers should note the Company’s stated PA stance and the alternate terminology in member documents when verifying authorization requirements before scheduling services.

• Data Call template: no PA required for any Med/Surg or MH/SUD services.
• Certificates of Coverage replace the term "prior authorization" with "Medical Management Techniques" and/or "Predetermination."
• Provider-facing materials and COCs lack consistent, clear explanation of how PA/CR/RR reviews are submitted and handled.

Expect RR post-service and risk of post-payment denials

Retrospective Review (RR) is used operationally to determine medical necessity or benefit coverage after services are rendered for both Med/Surg and MH/SUD; the Company’s UM file shows RR applied post-service and the Division expressed concern that paid claims may later be denied because RR is performed after adjudication.

• RR is defined by the Company as a utilization management process that occurs after a service is rendered.
• Examination team noted operational use of RR post-service and raised concern providers/members cannot rely on payment certainty.
• UM submission contained no MH/SUD UM records and only 12 Med/Surg records, limiting ability to validate RR application.

Address UM NQTL violations — targeted exam, fixes, and possible reprocessing

Reviewers found Utilization Management/Medical Management NQTL violations: the Company’s 'as written' vs 'in operation' UM processes are not comparable and were applied more stringently to MH/SUD than Med/Surg; the Division recommends targeted examinations, operational fixes, and possible reprocessing of affected claims.

• Finding: UM/Medical Management NQTL violation — in-operation processes are more stringent for MH/SUD than Med/Surg and MH/SUD UM services were not accurately tracked.
• Recommendation: Perform targeted market conduct exam or request Company action plan to remediate NQTL violations.
• Recommendation: Consider reprocessing claims and making consumers/providers whole where appropriate; improve comparative analysis documentation and in-operation UM data reporting.