If a Care Manager is unable to approve an authorization request due to a question of medical necessity, the request is sent to a Clinical Peer Reviewer to make a medical necessity determination.
- A Clinical Peer Reviewer is a North Carolina-licensed physician or psychologist with expertise in the condition or service being reviewed.
- The Peer Reviewer reviews clinical information submitted for review against the service criteria found in the applicable Clinical Coverage Policy or Service Definition.
- If the request is for a child under age 21, the request is reviewed against EPSDT criteria.
- The Peer Reviewer may contact the treating physician or clinician to have a peer-to-peer discussion about the case before making a determination.
- The Peer Reviewer then issues a determination to approve, deny or partially approve the requested service intensity and duration. If the request is denied or partially approved, the member will be provided with a written notice outlining the basis for the decision and the process for appealing. For more information about the appeal process, please see the Member Rights page.
- If a peer-to-peer discussion does not occur before a decision is rendered, the provider may request a post-decision peer-to-peer discussion within three business days after the decision.
- A post-decision peer-to-peer discussion is not an appeal but, rather, an opportunity to discuss the case, the decision, and the reason for the decision.
- Vaya Health will attempt to schedule the peer-to-peer discussion with the same Peer Reviewer that issued the original decision; if that cannot occur, the discussion will be scheduled with an equivalently qualified Peer Reviewer.
- If the Peer Reviewer, based on new information from the peer-to-peer discussion determines that a different decision should have been rendered, he or she may change the decision.