Decisions by an ERA must be consistent. ERAs must review decisions regarding same or similar requests and validate the consistency of decisions from reviewer to reviewer. An ERA should not release a decision without checking previous cases for similarities. When two reviewers come to opposite conclusions, the ERA must be prepared to reconcile the cases to OPP and to the health plans, either by clearly distinguishing the presenting facts of each case or by documenting a change in the supporting evidence. If there is a change in a determination regarding the experimental or investigational status of a particular service, the ERA must support the change with evidence cited above.
Additionally, OPP expects that in cases where an appellant is seeking a retrospective review of already-provided services, reviewers will make a decision based on the date on which the services were rendered. Reviewers should not rely on evidence that was not published or otherwise available on the date the service was rendered.
OPP has developed the enclosed guidance for review of decisions for services considered to be experimental or investigational and asks that the document be provided to each reviewer at the time the case is sent out. In addition, OPP will include a cover letter with each such case to remind the ERA of OPP’s expectations and to identify services for which OPP may have received differing opinions. In many, if not most of the cases involving experimental/investigational treatments, OPP will ask that the ERA use a three-reviewer panel in order to render its decision. OPP also expects the ERAs to identify cases in which a three-reviewer panel will ensure a more thorough review of the services in question if OPP has not done so.
OPP is hopeful that this guidance and proposed additional screening and identification by OPP will result in a better external review process that is fair to patient, providers, and health plans.
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