Expedited Organization Determination Criteria and Process
Provider Type
- Participating Physician Groups (PPG)
An member or physician (regardless of whether the physician is participating with the plan) may request an expedited organization determination (EOD) from Health Net when the member or their physician believes that waiting for a decision under the standard time frame could place the member's life, health, or ability to regain maximum function in serious jeopardy.
EODs may not be requested for cases in which the only issue involves a claim for payment for services that the member has already received. However, if a case includes both a payment denial and request for services, the member has a right to request an EOD for the service request.
The member or the member's physician may submit the request either orally or in writing when asking for an EOD. A physician may also provide oral or written support for a member's own request for an EOD.
Requests for Medicare Advantage (MA) EODs may not be filed with the Social Security Administration District Offices or the Railroad Retirement Board.
Participating Physician Group Responsibilities
Participating physician groups (PPGs) must provide an EOD when the treating provider requests it, or supports the member's request, and indicates that applying the standard time frame could seriously jeopardize the life or health of the member or the member's ability to regain maximum function.
PPGs must promptly determine whether the request meets the established criteria for EOD processing, which is as quickly as the member's health permits, but no later than 72 hours.
If a PPG decides the request does not meet the criteria for an EOD review, the PPG must
- Automatically transfer the request to the standard 14-day review.
- Provide the member or authorized representative oral notice (within 72 hours) of the denial of expedited status, including the member's right to file an expedited grievance.
- Oral notice is followed by written notice to the member within three calendar days. The notice explains:
- Transfer and processing the request using the 14 day time frame.
- The member's right to file an expedited grievance if he or she disagrees with PPG's determination.
- The member's right to resubmit a request for an EOD and that if the member's physician provides supporting documentation indicating that applying the standard time frame for making determinations could seriously jeopardize the life or health of the member or the member's ability to regain maximum function, the request is expedited automatically.
- The expedited grievance process and its time frame.
If a PPG decides the request meets the EOD criteria, but the service is denied due to lack of medical necessity, or other reason, the PPG must:
- Oral notice is followed by written notice to the member within three calendar days. The notice explains:
- Notify the member orally within 72 hours.
- Provide a written notice within three calendar days after providing the oral notice. When completing the standardized notice PPG indicates the specific reason for the denial that takes into account the member's presenting medical condition, disabilities, and special language requirements.
If a PPG decides the request meets EOD criteria and service is authorized, the PPG must:
- Notify the member of its approval determination as expeditiously as the member's health condition requires, but no later than 72 hours after receiving the request. The PPG may notify the member orally or in writing. Mailing the determination within 72 hours is not sufficient; the member must receive the notice within 72 hours.
The PPG may extend the 72-hour time frame by up to 14 calendar days if the PPG justifies a need for additional information and documents how the delay is in the best interest of the member. When PPGs extend the time frames, they must notify the members in writing of the reasons for the delays, and inform members of the right to file expedited grievances if they disagree with the PPGs' decision to grant an extension. PPGs must notify members of determinations as expeditiously as the members' health conditions require, but no later than the expiration of the extension.
If PPGs fail to provide members with timely notice of EODs, this failure in itself constitutes an adverse organization determination and may be appealed.
PPGs must maintain tracking logs for all service requests (including oral requests) in accordance with the Centers for Medicare & Medicaid Services (CMS) guidelines.
Health Net and its participating physician groups (PPGs) are required to maintain tracking logs for all service requests and denials in accordance with the Centers for Medicare & Medicaid Services (CMS) guidelines. The tracking log must include a code or another identifying method to distinguish expedited organization determinations (EOD) from other service requests and denials. Health Net reviews and maintains all logs for reporting purposes.
PPGs are not required to submit copies of any service denial letters, unless specifically requested by Health Net or Health Services Advisory Group (HSAG), California's Quality Improvement Organization (QIO). Only copies of the EOD Organization Determinations, Appeals, and Grievances (ODAG) tracking logs are submitted to the plan. Refer to the Calendar of Required PPG Submissions document for information regarding submission dates.
To ensure accurate reporting, the plan provides an EOD (PDF) ODAG tracking log, which includes submission information. Contact the Delegation Oversight Department to obtain an electronic copy in Microsoft Excel (log must be in Microsoft Excel format).
In accordance with the Health Insurance Portability and Accountability Act (HIPAA) privacy requirements, documents containing protected health information (PHI) cannot be submitted via standard, unsecured email; therefore, the plan does not accept tracking logs via standard electronic means. PPGs must submit EOD ODAG tracking logs to the Delegation Oversight Department or the Program Accreditation Department at UMQIMR@healthnet.com. The Delegation Oversight Department reviews and maintains all logs for reporting purposes. For additional information regarding submission of EOD ODAG tracking logs, contact the Delegation Oversight Department.