2.1.1.1 Will conduct reviews of medical records, clinical documentation, utilization guidelines, and applicable policies or regulations. The number of reviews vary from month to month. All relevant documentation will be submitted to Contractor via the Contractor’s secured portal for review. 2.1.1.2 Provide a written clinical rationale for each determination to the Office of Appeals, that includes a copy of any and all medical criteria or clinical guidelines relied upon in support of the recommendation. 2.1.1.3 Written recommendations shall include a summary of all medical documentation reviewed, a summary of the question(s) raised on appeal, a recommendation regarding the question(s) raised on appeal, the reviewer’s detailed, supporting rationale for recommendation, and a comprehensive list of any references used to make a recommendation. If references are utilized by the Medical Providers in the recommendations, a copy of or active link to the referenced documents must be provided with the recommendation. 2.1.1.4 Format of the written recommendation shall be subject to the approval of the Office of Appeals Director subsequent to the award. 2.1.1.5 Standard Requests: Written, detailed recommendations shall be provided to DOM seven (7) business days after the initial request and supporting documentation are submitted via the secured portal...
