Medical_Review_Format.pdf

[Insert Member’s Name and Identification Number]

FEHB PLAN

[Insert Name of FEHB Plan]

PATIENT

[Insert Member’s Name]

FEIO CONTROL NUMBER

[Insert OPM Case Identification Number]

ENROLLEE

[Insert Enrollee’s Name]

I.D. NUMBER

[Insert Patient/Enrollee’s Health Plan Identification Number]

DATE

[Insert Date the Medical Review was Completed]

MEDICAL REVIEW ANALYSIS REPORT

Case#: [Insert Identification Number for the Medical Review. This number must correspond with the number assigned to the medical record on the Task Order Invoice.]

STATE IDENTIFIED ISSUE/SERVICE(S) UNDER APPEAL/REVIEW:

Insert a copy of the question (s) posed by OPM to the medial /dental or coding specialist reviewer.

[Reiterate the medical review issue written by the OPM staff on the FEHB medical inquiry form which fully describes the medical issue for which a review analysis is being sought and includes relevant information/medical records concerning the member's prior approval request or disputed claim, and specific Health Plan definitions and benefits.]

Adequacy of Medical Records and Clinical Information:

Documentation Submitted for Review:

[List all dates of service and type of clinical documents provided by OPM]

U.S. OFFICE OF PERSONNEL MANAGEMENT

FEDERAL EMPLOYEE INSURANCE OPERATIONS

[Insert Member’s Name and Identification Number]

State Case Clinical Findings and Analysis:

Reviewer Assessment of Record that will provide a detailed written narrative of the clinical record that at a minimum includes the following:

• Demographics (age, gender, diagnosis, date of diagnosis, etc.)

• Statement describing the service/benefit request in dispute

• Sequentially report key clinical events (examination dates, procedure dates, inpatient admission/discharge dates, inpatient unit transfer dates, etc.)

• Consecutively report relevant clinical findings (vital signs, examinations, diagnostic study results, rehabilitation/medical therapy evaluations, etc.)

Provide a specific determination on the service/benefit request in dispute based upon the independent review of the clinical record and as the record relates to the Health Plan’s rationale for denial of the service/benefit request (as described in the questions posed by OPM to the reviewer) that at a minimum includes the following:

• Provide your answer to the review issues presented by OPM. It is not sufficient to only state your conclusion (e.g. “medically necessary”). You must provide peer defensible rationale based on the clinical record and references.

• The determination statement(s) cites current nationally recognized medical and scientific evidence/literature and clinical practice guidelines.

• When applicable, the determination statement(s) cites the absence of current nationally recognized medical and scientific evidence/literature and clinical practice guidelines and the rationale for the absence of this supporting evidence.

• All reviewer responses must be in accordance with the Health Plan definitions and the benefit coverage criteria supplied by OPM.

References Cited by Reviewer:

[Insert references/clinical practice guidelines cited/utilized in the formulation of the reviewer response. When applicable, state the absence of medical and scientific literature]

Answers to Specific Questions:

Reviewer Signature Page:

• Legible printed or typed name of the reviewer

• Reviewer signature with professional designation (M.D., D.O., D.D.S., etc.) and listing of board certification(s)

• Legible printed list of the reviewer’s medical/dental specialty(s) and sub-specialty(s); coding specialist credential(s)

• Conflict of interest disclosure statement