UM Expedited Appeals

August 3, 2017

Utilization Management (UM) appeals allow patients, attending providers, and family members to challenge an adverse determination based on a health plan decision that the care is not medically necessary or clinically appropriate. In instances where there is imminent danger to a patient’s life or limb, an expedited appeal may be necessary.

To examine current trends in this important aspect of medical management, RegQuest produced the 2016 UM Trend Report, highlighting that 39 states and Puerto Rico have established expedited timeframes for UM appeals. The majority of those states require a determination within 72 hours, but not all, despite the NAIC Model Act’s encouragement that expedited appeal decisions be issued within 72 hours. The result is inconsistency and lack of uniformity across the states. In addition, a related concern is that 11 states have not adopted any regulations governing expedited UM appeal timeframes.

The variation in the expedited appeals timelines makes it difficult for consumers to navigate, and further complicates an already confusing and complex system. Despite the NAIC’s efforts to standardize UM appeals, not all states are implementing such changes, making it difficult for UM providers and issuers that do business in multiple states to properly track state regulations. In response, regulatory and accreditation agencies are beginning to implement more specific timeframes for different types of appeals and ensuring those timeframes are enforced. Ultimately, the goal is to create a more unified appeals system across the states so that regulations are both easily understood and properly followed.

RegQuest provides access to an efficient resource that includes a comprehensive, up-to-date compilation of state specific UM, ER, and Grievance Procedure regulations. With easy online navigation, you can review state surveys, trend reports, blogs and more. To access the table with each state’s appeals timeframes, visit regquest.com to become a subscriber or contact us for more information about subscribing or renewing your subscription.