A Few Items To Ensure You Analyze

Analysis should be performed on all TPAs, PBMs, networks, direct contracting agreements, carve out programs, utilization review, concurrent review and any medical management programs.  Essentially everything in the plan must be evaluated and documented in regard to NQTL.  Some examples include:

• Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative;
• Prior authorization or ongoing authorization requirements;
• Concurrent review standards;
• Formulary design for prescription drugs;
• For plans with multiple network tiers (such as preferred providers and participating providers), network tier design;
• Standards for provider admission to participate in a network, including reimbursement rates;
• Plan or issuer methods for determining usual, customary, and reasonable charges;
• Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective (also known as “fail-first” policies or “ step therapy” protocols);
• Exclusions of specific treatments for certain conditions;
  Restrictions on applicable provider billing codes;
• Standards for providing access to out-of-network providers;
• Exclusions based on failure to complete a course of treatment; and
• Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage.