Important Information On
Notice of Adverse Benefit Determinations (NABDs)
This update was made as a requirement from HSAG (Health Services Advisory Group). This update was approved by the Statewide Customer Service group. Please work with us while we work out the details and bugs. If you notice a concern, please reach out to customer services.
CHANGE IDENTIFIED
Legal Citation Page: Must have a legal citation to move forward.
*If you click on a "Reason for Action" that does not generate a legal citation, you will see this box
Click "OK" and go back to save and continue to citations.
You must enter a legal citation, or it will not let you save and complete the document.
CHANGE IDENTIFIED
Here are some of the common citations that are not self-populate.
-
No legal citation is generated for these options. PCE will not let you complete the NABD without the legal citation. Please use the legal citations below in the following examples.
- (Other) – HealthWest does not have the provider capacity to provide the service (s).
- LEGAL CITATION: Denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit. 42 CFR 438.400 (b)(1).
MDHHS Medicaid Provider Manual, Behavioral Health and Intellectual and Developmental Disability Supports and Services chapter, Section 2.5 A-D, Medical Necessity Criteria
- LEGAL CITATION: Denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit. 42 CFR 438.400 (b)(1).
- (Delay) - Your services were not provided within 14 calendar days of the start date agreed upon during the person-centered planning process.
- LEGAL CITATION: Failure to provide services within 14 calendar days of the start date agreed upon during the person-centered planning and as authorized by the PIHP. Managed Care Rule 42 CFR 438.400(b)(4).
- (Delay) - Your service authorization decision was delayed more than 14 calendar days from the receipt of your request.
- LEGAL CITATION: Failure to make a standard Service Authorization decision and provide notice about the decision within 14 calendar days from the date of receipt of a standard request for service. Managed Care Rule 42 CFR 438.210(d)(1).
For denials, PCE will automatically follow the logic to create legal citations for the following reasons for action:
-
You do not meet eligibility criteria for services as a person with a serious mental illness.
- AND/OR
- … a child with a serious emotional disorder.
- AND/OR
- … a person with a substance-use disorder
- The clinical documentation provided does not establish medical necessity.
- Based on medical necessity, a provider can deny services that are deemed ineffective, experimental, or for which there exists another appropriate service.
- Based on medical necessity, supports, services, and treatment authorized by the provider must be provided in the least restrictive, most integrated setting.
*It has come to our attention that legal citations will not populate for non-Medicaid NABDs. Although the legal citations have not processed previously, now with the updated version, it will not let you sign your NABD without the legal citations. Please see the document below for more information.
DENIAL DETAILS
-
Is this the initial denial/delay of request - yes
-
Requesting individual - usually the member
-
Extension applied - If you completed this more than 14 days of the request, you will need to apply the extension and reach out to customer services.
-
Type of case - Standard, unless you are doing an inpatient denial, then it is expedited.
DENIAL STATEMENTS
A denial statement refers to the information input by staff used to inform a person that their services have been impacted. A denial statement gives the reason, or reasons, for the notice of AB, and the policy and/or authority that was relied upon to make the determination. It is the "story" about what services were requested, what treatment was received, what behaviors have been observed, why the care is not medically necessary, and describes the appropriate level of care, if any, available to address the person's needs.
Denial statements must include the information necessary to support the denial of services. The information needs to be in understandable language so that the individual knows why a service is being denied.
Denial statements serve as the basis for defending a decision when there is an appeal or hearing.
- The denial rationale and evidence to support the denial
- A specific statement about why the services are not medically necessary
- A recommendation for an alternative level of care to meet the person's current needs, if applicable
- Identification of the specific services under review, a brief personalized description of why the person was receiving services (if they were), and the relevant symptoms/behaviors the person was having at the time of the request.
- A description of the treatment the person received if they have been receiving services.