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Decision Time Frames
Utilization review determinations are made in a timely manner and in compliance with applicable law.
• Emergent - authorization not required in accordance with applicable law
• Urgent - within 48 hours or next business day
• Expedited – with 72 hours or as required by the health status of the Member
• Routine - within 14 days of the receipt of the request
Bravo Health recognizes the need for prompt handling of all referrals and will communicate directly
with the requesting Provider’s office all rendered decisions via telephone communication and/or
facsimile.
Denials
Efforts are made to obtain all necessary information, including pertinent clinical information from the
treating Provider to allow the Medical Director to make coverage determinations. The Medical Director
is available by telephone to the Provider to discuss determinations based on medical necessity. A denial
may occur:
a. At the time of prospective pre-service review. The process for discussion of such denials
between Bravo Health’s Medical Director and the Provider of care will be documented by
the UM department staff and processed according to the adverse decisions policy.
b. At the time of concurrent review, the health plan will notify the acute facility via facsimile or
verbally within 24 hours after receipt of all clinical information needed to render a
determination. Denial notification is sent to the facility and patient (only when in a non-
Contracting facility) in writing at the end of the admission stay. A copy of the letter is also
sent by mail to the attending Provider notifying him/her of any downgrade or denied
determination.
c. At the time of a request for authorization for a non-Covered service.
Rendering Denials
a. The Utilization Management staff can make the decision for an administrative denial based on
Covered Services, eligibility, etc.
b. Only the Medical Director makes the decision for denial based on medical necessity but he/she
can also make a decision on administrative guidelines. The Medical Director, in making the
initial decision, may elect to suggest an alternative Covered Service to the requesting Provider.
A denial notice is issued documenting the original request that was denied and the alternative
service and the process for appeal. If the Provider agrees, he/she notifies the Member.
Notification of Denials
a. The reason for each denial, including the specific utilization review criteria or benefits
provision used in the determination of the denial are included in the written notification and
sent to Members and Providers.
b. The criteria used to determine the coverage is available to the Provider and Member upon
request.
