HomeMy WebLinkAboutContract 46250-AD1 CtrY SECRETARY
CONTRACT NO. I I
COVERAGE DETERMINATION AND APPEALS PROCESS ADDENDUM
This Coverage Determination and Appeals Process Addendum (hereinafter "Addendum") is
entered into by and between Envision Pharmaceutical Services, Inc. (hereinafter"Envision") and
the City of Fort Worth (hereinafter "Plan Sponsor") as follows. This Addendum is effective
January 1St,2015 (hereinafter the "Effective Date").
BACKGROUND
Envision and Plan Sponsor are parties to a Pharmacy Benefit Management Services Agreement
dated January 1St, 2015 (hereinafter "Agreement") under which Envision provides PBM Services
to Plan Sponsor. Plan Sponsor wishes for Envision to provide additional services under the
Agreement as set forth below.
NOW THEREFORE, Envision and Plan Sponsor agree as follows:
1. Initial Coverage Determinations and Appeals: Envision shall administer a Coverage
Determination and Appeals Process under Plan Sponsor's direction as described in Exhibit 1-A.
The Coverage Determination and Appeals Process will include: (i) Real-time adjudication to
determine coverage/non-coverage status of a Claim; (ii) Initial Determinations (including
Clinical Prior Authorizations); (iii) Redeterminations ("Internal Appeals"); and (iv) External
Appeals utilizing an Independent Review Organization (IRO). The Coverage Determination and
Appeals Process will meet the requirements of the Department of Labor's Internal Claims and
Appeals and External Review Processes under 29 CFR §2590.715-2719.
2. Compensation: Plan Sponsor shall pay Envision the following fees:
Provided. Internally by Envision
Coverage Determinations (including Clinical Prior $8.00 each
Authorizations)
Redeterminations(Internal Appeals) $85.00 each
External Reviews Performed by IRO
Standard Turnaround Time (2 days or greater) 100%pass through
Standard Turnaround Time for Complex Independent invoiced amount from IRO
Review*
Expedited Turnaround Time (within 72 hours)
Expedited Turnaround Time for Complex Independent
Review*
*Complex Independent Review is defined as requiring greater than one hundred pages of clinical
documentation
3. All other terms and conditions of the Agreement not modified by this Addendum or any
prior amendment or addenda shall remain unchanged.
OFFICIAL RECORD
CITY SECRETARY
FT- WORTH RECEIVED DEC 1 P.M.
Appeals Process Addendum 120412 � TX
IN WITNESS WHEREOF, Envision and Plan Sponsor have executed this Addendum as of the
Effective Date above.
For ENVISION: For PLAN SPONSOR:
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\Appeals Process Addendum 120412
EXHIBIT 1-A
EnvisionRxOptions
Coverage Determination, Redetermination (Internal Appeal) and Independent Review
(External Appeal) Program Description
(Revision date 12/04/2012)
Envision maintains a process for Coverage Determinations (including Clinical Prior
Authorizations), Redeterminations, and External Reviews (Independent Review Organization
submissions). Envision utilizes a claim adjudication platform to determine real-time
coverage/non-coverage status for Claims submitted electronically at the Point-of-Sale. Claims
failing one or more Benefit Plan coverage rules are rejected at the Point-of-Sale and information
regarding the reject reason(s) is conveyed to the dispensing pharmacy at the Point-of-Sale.
Pharmacy personnel may contact Envision's Customer Service Department to begin the
Coverage Determination process or they may inform the Member of the reason(s) for the
rejection and provide the Member with instructions to contact the Customer Service Department
in the event the Member would like to initiate a Coverage Determination.
Coverage Determinations (or Clinical Prior Authorizations)
When a Coverage Determination request is initiated, the information connected with the rejected
prescription is conveyed by Envision to the Prescriber via fax with a request for specific
information regarding the Member's medication history and disease diagnosis. The Prescriber
completes the form and returns it to Envision where the information provided by the Prescriber is
evaluated by an Envision clinical pharmacist. Expedited Coverage Determinations occur as soon
as possible, taking into account medical exigencies, but no later than 24 hours of receipt of the
request and standard determinations occur within 72 hours of receipt of the request.
If the information provided meets the criteria to allow an override of the initial rejection, an
override will be configured in the adjudication system that will allow the Claim to process. If the
clinical review determines the prescription fails to meet the coverage criteria, the prescription
will remain in rejected status.
The result of the Coverage Determination is communicated to the Member by written letter, the
Prescriber by fax, and the dispensing pharmacy by fax. In the event the Coverage Determination
results in an Adverse Benefit Determination, as defined below, the notice to the Member and
Prescriber includes information identifying the Claim involved, the specific reason for the
Adverse Benefit Determination, instructions about the right to initiate a Redetermination
(Internal Appeal), a link providing the availability and contact information of an agency offering
assistance to the Member with the appeals and external review processes, if one is available, and
may contain additional information as directed by Plan Sponsor.
An Adverse Benefit Determination is a denial, reduction, or termination of, or a failure to
provide or make payment (in whole or in part) for, a benefit, including any such denial,
reduction, termination, or failure to provide or make payment that is based on a determination of
a participant's or beneficiary's eligibility to participate in a plan, and including, with respect to
\Appeals Process Addendum 120412
5
group health plans, a denial, reduction, or termination of, or a failure to provide or make payment
(in whole or in part) for, a benefit resulting from the application of any utilization review, as well
as a failure to cover an item or service for which benefits are otherwise provided because it is
determined to be experimental or investigational or not medically necessary or appropriate. 29
CFR 2560.503-1(m). An Adverse Benefit Determination also includes any rescission of coverage
as defined in the regulations restricting rescissions (26 CFR 54.9815-2712T(a)(2), 29 CFR
2590.715-2712(a)(2), and 45 CFR 147.128(a)(2)), whether or not there is an adverse effect on
any particular benefit at that time.
The availability and contact information of an agency offering assistance to the Member with the
appeals and external review processes can be found at: www.healthcare. ov/using-
insurance/managing/consumer-help/index.html.
Redetermination (Internal Appeal)
Upon initiation of a Redetermination by the Prescriber or Member (or the Member's appointed
representative), additional supporting documentation may be requested by Envision from the
Prescriber. Expedited Redetermination request evaluations occur as soon as possible, taking into
account medical exigencies, but no later than 72 hours of receipt of the request to allow the
Member to submit additional information for consideration, and standard evaluations occur
within 72 hours of receipt of the request. The evaluation is performed by a clinical pharmacist or
pharmacists other than the pharmacist or pharmacists that reviewed the original Coverage
Determination request, to maintain impartiality within the review process.
Envision will allow a Member to review the claim file and to present evidence and testimony as
part of the Internal Appeals process. Envision will provide the Member, free of charge, with any
new or additional evidence considered, relied upon, or generated by the Redetermination as soon
as possible and sufficiently in advance of the date on which the notice of an Adverse Benefit
Determination is required to be provided, to give the Member a reasonable opportunity to
respond prior to that date.
If the Redetermination information supports an override of an Adverse Benefit Determination, an
override will be configured in the adjudication system which will allow the Claim to process. If
evaluation determines the Redetermination request fails to meet the coverage criteria, the Claim
will remain in rejected status.
The result of the Redetermination is communicated to the Member by written letter and the
Prescriber by fax. In the event the Redetermination results in an Adverse Benefit Determination,
the notice to the Member and Prescriber will include information identifying the Claim, the
specific reason for the Adverse Benefit Determination including a discussion of the decision
including the plan provision relied upon, instructions about their right to initiate an External
Review, if applicable, a statement that the Member has a right to bring a civil action under
ERISA Section 502(a) following a denial upon appeal, a link providing the availability and
contact information of an agency offering assistance to the Member with the external review
process, if one is available, and may contain additional information as directed by Plan Sponsor.
\Appeals Process Addendum 120412
The Member may, upon request and free of charge, receive reasonable access to and copies of all
documents, records, and other information used in the Coverage Determination
The availability and contact information of an agency offering assistance to the Member with the
appeals and external review processes can be found at: www.healthcare.gov/using=
insurance/managing/consumer-help/index.html.
External Appeal Independent Review Organization)
A Member may file a request for an External Review with the plan within four months after the
date of receipt of notice of a final Adverse Benefit Determination. The Redetermination (Internal
Appeal) process must be exhausted before an External Appeal is requested; however a
simultaneous request for a Redetermination and an External Appeal may be made in an urgent
care situation. When a Member (or the Member's duly appointed representative) initiates an
External Appeal request, Envision will complete a preliminary review of the request within five
business days of receipt for a standard request and immediately if expedited. This preliminary
review will determine (i) if the Member was covered under the Benefit Plan on the date of
service, (ii) if the rejection does not relate to the Member's failure to meet the requirements for
eligibility, (iii) if the Member has exhausted the Plan Sponsor's internal appeal process, and (iv)
if the Member has provided all information required to process an External Review.
After the preliminary review is complete, Envision will issue a notification in writing to the
Member. Notice will be sent immediately for expedited requests and within one business day
after the completed preliminary review for standard requests. If the request is complete, but
determined to be ineligible for External Review, the Member notification will include the reason
the Claim has been determined to be ineligible and contact information for the Employee
Benefits Security Administration. If the request is incomplete, the Member notification will
specify the information needed to make the request complete. The Member will have an
opportunity to provide the needed information within the four month filing period, or within 48
hours of receiving the notification, whichever is later.
Once the preliminary review has been determined to be complete for an External Review,
Envision will provide the Claim information, Benefit Plan exclusion and coverage criteria
documentation, and clinical review criteria to an Independent Review Organization (IRO).
Envision has contracted with three IROs. External Appeal requests are assigned to the IROs by
rotation to avoid selection bias. Each contracted IRO holds URAC accreditation status to
conduct External Reviews. The IRO is not bound by the previous Redetermination decision and
reviews each case in accordance with the terms of the Benefit Plan and coverage documentation.
The IRO will notify the Member once it receives the Member's claim information and the
Member will have ten business days to submit any additional information for the IRO to consider
in its External Appeal.
The IRO will convey a final decision to Envision and the Member within 45 days for standard
reviews and within 72 hours for expedited reviews. Expedited reviews are permitted when
standard review timeframes would seriously jeopardize the life or health of the Member.
�Appeats Process Addendum 120412
If the IRO reverses Envision's adverse Redetermination decision, then Envision will provide
coverage and/or payment of the Claim within twenty-four hours of notification of the IRO
decision. If the IRO upholds Envision's Adverse Benefit Redetermination decision, the IRO will
communicate the decision to Envision and the Member. If the Prescriber files the request on
behalf of the Member, then the Prescriber will be notified as well. The Member and Prescriber
(if applicable) are provided letters with the specific reasons including the plan provision relied
upon for the Adverse Benefit Determination, a statement that the Member may, upon request and
free of charge, receive reasonable access to and copies of all documents, records, and other
information used in the Coverage Determination, if applicable, a statement that the Member has
a right to bring a civil action under ERISA Section 502(a) following a denial upon appeal, and
may contain additional information as directed by Plan Sponsor.
The IRO's decision is binding, except to the extent that other remedies (including judicial review
of the decision) may be available under applicable law to either the Plan or the Member.
\Appeals Process Addendum 120412