ALLIANCE FOR FERTILITY PRESERVATION INSURANCE ACCESS - 2016

How To Use California’s Department Of Managed Health Care’s (DMHC) Independent Medical Review (IMR) Process ALLIANCE FOR FERTILITY PRESERVATION INSURANCE ACCESS - 2016

PURPOSE The primary barrier to fertility preservation services for cancer patients is the high cost of treatment and the concomitant lack of insurance coverage. As part of its advocacy work, the Alliance for Fertility Preservation has launched an initiative in California. The purpose of this project is to try to use the California Department of Managed Healthcare’s online redress process to: Obtain Independent Medical Reviews (IMRs) of coverage denials for fertility preservation for cancer patients; and, ultimately, To achieve coverage as a part of all DMHC plans. ACCESS

BACKGROUND: THE DMHC & ITS IMR PROCESS The DMHC regulates most of the managed healthcare plans in the state of California The DMHC has created a process for patients to challenge their insurer’s denial of coverage by requesting an Independent Medical Review (IMR) review of their case The process is initiated through a simple, online form The IMR provides an objective review of the patient’s coverage request by independent doctors Review usually takes 30 days, but urgent requests can be expedited for 7 day review

YOUR ROLE Be willing to engage all eligible patients in the process Any of your AYA patients who are interested in fertility preservation should be informed of this process Use the AFP materials and website resources that are provided, to make the process as easy as possible Reach out to the AFP or directly to the DMHC for assistance if needed DMHC helpline: 1-888-466-2219 | info@allianceforfertilitypreservation.org Support each patient throughout the several steps needed to ensure completion of the process SUBMIT requests for Independent Medical Reviews!

STEP 1: CONFIRM DMHC PLAN Once you have identified an interested patient, check to see whether the patient’s insurance is provided by a plan that is regulated by the DMHC These plans cover 25 Million Californians! The DMHC regulates 122 plans A complete list of plans can be viewed here: http://wpso.dmhc.ca.gov/hpsearch/viewall.aspx

STEP 2: SEEK PRE-AUTHORIZATION Call the patient’s insurance provider to seek pre-authorization for the fertility preservation services that the patient is seeking Patients may not (often do not) have any infertility coverage as a part of their plan; pre-authorization should be sought regardless Almost no patients have coverage in place for fertility preservation, so the request for pre-authorization will usually be denied Upon verbal denial of a pre-authorization request, move quickly to begin the appeals process

STEP 3: APPEAL If the plan representative tells you that the fertility preservation procedures are not covered, you must draft an appeal letter Submit the appeal letter through the individual plan’s appeal mechanism The appeal letter: Must be marked URGENT Should clearly state the medical necessity for the services sought Should include citations to support the argument that these treatments are now considered the standard of care The AFP has template appeal letters and citations for your use Urgent appeals should be responded to within 72 hours

STEP 4: RECEIVE DENIAL OF COVERAGE Once the formal, urgent appeal letter on behalf of the patient is submitted, you should receive a response within 72 hours; if you do not, you should follow up with the plan If the appeal letter is reviewed but coverage is still denied, the patient will receive a written denial of coverage Receipt of the written denial of coverage allows for the initiation of the online independent medical review (IMR) process You cannot begin the IMR process until the formal denial is received

STEP 5: FILL OUT IMR FORM Go to: https://wpso.dmhc.ca.gov/imrcomplaint/default.aspx?c=1 to access the online form If you are submitting the form on behalf of a pre-treatment patient, be sure to indicate that the request for review is URGENT There is no checkbox for this, so you must include this in the body of the text explaining why the patient is seeking an appeal (see relevant section below)

STEP 5: FILL OUT IMR FORM (CONT.) It may be helpful to include language explaining that the procedures sought are now considered “standard of care” (if applicable) and/or including citations to support coverage For template examples and citations, go to: http://www.allianceforfertilitypreservation.org/insurance-resources Be sure to attach a copy of the written denial of coverage from the insurance plan Remember, the request for review is technically being submitted by the patient, so the patient must “sign” (electronically) the online form IMRs can be requested up to 6 months after the patient receives a written denial of coverage from the insurer; this may apply to patients who were denied coverage and paid out-of-pocket for fertility preservation services

STEP 6: SUBMIT! Please work with all of your eligible patients to SUBMIT requests for IMRs The IMR process is a totally free, underutilized resource for California residents who have managed care insurance – 25 million people! Once the IMR is issued, it will appear online in the DMHC database of IMR decisions. These decisions are publicly available and searchable at: http://wpso.dmhc.ca.gov/imr/ Getting fertility preservation IMRs issued, even if they uphold the insurer’s denial of coverage, is critical to helping us alert the DMHC to this largely unmet coverage need IMRs that do result in overturning a coverage denial not only help your individual patient, but also set a precedent which will assist in laying a foundation for policy change

THANK YOU Thank you to Mary Watanabe at the California DMHC for explaining this process and providing background information. Thank you to EMD Serono for providing funding for this project.

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ALLIANCE FOR FERTILITY PRESERVATION INSURANCE ACCESS - 2016