J-23 Medical Review Process.pdf

Medical Review Process

Introduction The World Trade Center (WTC) National Responder Health Program (NRHP) will provide medical treatment for conditions that have been determined by science and medical experts to be related to exposure during the rescue, recovery and clean up of 9/11. Responders or their authorized representatives may request a medical review of the following coverage decisions which have been made in the course of providing treatment services authorized under this program. In order to be eligible for this process, you must have a completed monitoring exam within the past 12 months on file with the WTC

NRHP.

Non-covered health condition – To request a review of a non-covered health condition, the following information must be submitted for consideration to the address below: medical documentation from your treating physician that demonstrates the relationship between presenting medical problems and the existing WTC-covered condition. This documentation may include, but is not limited to, scientific evidence of the natural disease progression, complications, exacerbation of the condition and related research. The ICD-9-CM diagnosis code must be included in the request along with a treatment plan.

Non-covered procedure – To request a review of a non-covered procedure, the following information must be submitted for consideration to the address below: medical documentation from your treating physician that demonstrates the relationship between presenting medical problems and the requested procedure. The request must include the Current Procedural Terminology (CPT) code(s) along with a treatment plan.

Non-covered medication (formulary) request – To request a review of a non-covered medication, the following information must be submitted for consideration to the address below: medical documentation from your treating physician that demonstrates the relationship between presenting medical problems and the requested medication. This information must include the name of the medication, generic name, dose, and treatment plan.

Whenever a diagnosis, procedure or medication claim is denied by the Logistics Health Incorporated (LHI) Medical Director of the WTC NRHP for one of these reasons, the responder shall be sent a letter of denial which mentions the right to request a medical review and encloses a Medical Review Fact Sheet and a Medical Review Request Form (Request Form) that is attached.

Medical Review Process

1. The medical review process begins when a responder or their authorized representative submits, the

Request Form and necessary documents as described above to the LHI Medical Director at the following location:

WTC National Responder Health Program WTC Medical Operations Department Logistics Health, Incorporated 328 Front Street South La Crosse, WI 54601

2. The Request Form must be submitted within 60 working days of the denial of service or claim (late submissions will considered on a case by case basis pending review by the WTC NRHP Medical Operations Department).

3. The Request Form must include written support by a WTC treatment physician. This written support must include the WTC treatment physician’s medical basis for the medical review.

4. The WTC Medical Operations Department will examine all documentation to determine if a denied claim was processed correctly, and verify that a request for coverage or a claim was denied for one of the above reasons: non-covered health condition, non-covered procedure and/or non-covered medication.

20090915 Page 1 of 2

Medical Review Process

20090915 Page 2 of 2

5. The WTC Medical Operations Department will acknowledge to the responder or authorized representative in writing within 3 working days of receipt of the Request Form.

6. All medical review documents will be sent to the NIOSH WTC Program Medical Director by the LHI

WTC Medical Director within 30 working days of receipt.

7. The NIOSH WTC Program Medical Director will use whatever resources determined appropriate to make a decision on the medical review within 30 working days of receipt. The decision will be based on the specific medical needs of the responder and any of the following factors:

• Expert consensus by the WTC Program Consortium or others.

• Peer-reviewed scientific and medical evidence regarding the appropriateness of the contested health care service.

• Nationally recognized professional standards.

8. The decision of the NIOSH WTC Program Medical Director will be one of the following:

• Denial of the medical review request, or

• Approval of the medical review request as an exception to program policy

• Approval of the medical review request as a new coverage by the WTC Program

9. The decision of the NIOSH WTC Program Medical Director will be communicated to the LHI WTC

Medical Director within 3 working days of the decision.

10. Upon receiving the decision of the NIOSH WTC Program Medical Director, the LHI WTC Medical

Director will acknowledge receipt of the decision and will inform the responder/authorized representative of the outcome of the medical review, in writing, within 3 working days of receipt.

NOTE: If the medical review request is an emergency situation, the process will be expedited by using telephone communications and rapid transfer of information.

Attachments

• Medical Review Fact Sheet

• Medical Review Request Form

• Medical Review Package Cover Letter

Attachments