Part 4 – Utilization Review Requirements (continued) WORDS IN ITALICS ARE EXPLAINED IN PART 2. Page 30 this information or records within this time frame, Blue Cross Blue Shield HMO Blue will make a decision within two working days of the date it is received. Coverage Approval If Blue Cross Blue Shield HMO Blue determines that the proposed setting for your health care is suitable, Blue Cross Blue Shield HMO Blue will call the health care facility. Blue Cross Blue Shield HMO Blue will make this phone call within 24 hours of the time the decision is made to let the facility know of the coverage approval status of the pre-admission review. Then, within two working days of that phone call, Blue Cross Blue Shield HMO Blue will send a written (or electronic) notice to you and to the facility. This notice will let you know (and confirm) that your coverage was approved. Coverage Denial If Blue Cross Blue Shield HMO Blue determines that the proposed setting is not medically necessary for your condition, Blue Cross Blue Shield HMO Blue will call the health care facility. Blue Cross Blue Shield HMO Blue will make this phone call within 24 hours of the time the decision is made to let the facility know that the coverage was denied and to discuss alternative treatment. Then, within one working day of that phone call, Blue Cross Blue Shield HMO Blue will send a written (or electronic) notice to you and to the facility. This notice will explain Blue Cross Blue Shield HMO Blue’s coverage decision. This notice will include: information related to the details about your coverage denial; the reasons that Blue Cross Blue Shield HMO Blue has denied the request and the applicable terms of your coverage in this health plan; the specific medical and scientific reasons for which Blue Cross Blue Shield HMO Blue has denied the request; any alternative treatment or health care services and supplies that would be covered; Blue Cross Blue Shield HMO Blue clinical guidelines that apply and were used and any review criteria; and the review process and your right to pursue legal action. Reconsideration of Adverse Determination Your health care provider may ask that Blue Cross Blue Shield HMO Blue reconsider its decision when Blue Cross Blue Shield HMO Blue has determined that inpatient coverage is not medically necessary for your condition. In this case, Blue Cross Blue Shield HMO Blue will arrange for the decision to be reviewed by a clinical peer reviewer. This review will be held between your health care provider and the clinical peer reviewer. And, it will be held within one working day of the date that your health care provider asks for the Blue Cross Blue Shield HMO Blue decision to be reconsidered. If the initial decision is not reversed, you (or the health care provider on your behalf) may ask for a formal review. The process to ask for a formal review is described in Part 10 of this Subscriber Certificate. You may request a formal review even if your health care provider has not asked that the Blue Cross Blue Shield HMO Blue decision be reconsidered. Concurrent Review and Discharge Planning Concurrent Review means that while you are an inpatient, Blue Cross Blue Shield HMO Blue will monitor and review the health care services you receive to make sure you still need inpatient coverage in that facility. In some cases, Blue Cross Blue Shield HMO Blue may determine upon review that you will need to continue inpatient coverage in that health care facility beyond the number of days first thought to be required for your condition. When Blue Cross Blue Shield HMO Blue makes this decision (within one working day of receiving all necessary information), Blue Cross Blue Shield HMO Blue will let the health care facility know of the coverage approval status of the review. Blue Cross Blue Shield HMO Blue will do this within one working day of making this decision. Blue Cross Blue Shield HMO Blue will also send a written (or electronic) notice to you and to the facility to explain the decision. This notice will be sent within one working day of that first notice. This notice will include: the number of additional days that are being approved for coverage (or the next review date); the new total number of approved days or services; and the date the approved services will begin.