Slide 1: Implementation Council
Mar 8, 2022

Tufts Health Unify
Slide 2: One Care Rating Categories Definitions
Data is shown by rating category in this presentation. See rating category definitions below for reference:

F1 – Facility-based Care. Individuals identified as having a long-term facility stay of more than 90 days
C3 – Community Tier 3 – High Community Need. Individuals who have a daily skill need of two mor more Activities of Daily Living (ADL) limitations AND three days of skilled nursing need; and individuals with 4 or more ADL limitations
•	In CY2014, C3 split into two subsets:
o	C3B: for C3 individuals with certain diagnoses (e.g. quadriplegia, ALS, Muscular Dystrophy and Respirator dependence) leading to costs considerably above the average for current C3
o	C3A: for remaining C3 individuals
C2 – Community Tier 2 – Community High Behavioral Health. Individuals who have chronic and ongoing Behavioral Health diagnosis that indicates a high level of service need
•	In CY2014, C2 split into two subsets
o	C2B: for C2 individuals with co-occurring diagnoses of substance abuse and serious mental illness
o	C2A: for remaining C2 individuals
C1 – Community Tier 1 Community Other. Individuals in the community who do not meet F1, C2 or C3 criteria
Slide 3: Utilization Management Definitions
Approvals
A request is granted.

Approvals with Modifications (aka Partial Approvals)
A request has been granted with a decrease or substitute. 
Denials 
The request has not been granted. Examples include:
•	Procedural denials- claim filed incorrectly or duplicative
•	Member’s plan maximum benefit reached 
•	Request for out-of-network provider with in-network options available 
•	Medical necessity criteria not met
Slide 4: Prior Authorization – Decision Letters
•	Decision letters are sent in response to all prior authorization requests received
o	Services not requiring prior authorization do not result in a letter. Instead, the member is kept informed by their Care Partner and/or provider.
•	Decision letter content depends on outcome
o	Approvals outline: 
•	Services being approved as well as amount approved
o	Approvals with Modification* (Partial Approvals only) outline: 
•	What was approved compared to the original request
•	Why we made this change
•	Member appeal rights and instructions
o	Denials outline: 
•	Why we denied this request
•	Member appeal rights and instructions
•	Members can appeal modifications and denials themselves, or have a care partner/trusted individual assist in the appeal process

*Modifications that are considered "upgrades" are captured in the approvals category due to existing systems and processes
Slide 5: 96% of sent DME letters are Approvals
Of the 2861 DME requests from 1076 members since 2018* which resulted in a decision letter**:
•	96% were Approved
•	4% were Denied

Note: the following is shown in a pie chart on this slide.

DME Request Outcomes

Approved 96%
Denied 4%

Note: the following is shown in a bar chart on this slide.

DME Requests - Outcomes by Year

2018
Approved	773
Denied	29

2019
Approved	763
Denied	11

2020
Approved	587
Denied	14

2021
Approved	630
Denied	54

Note: the following is shown in a table on this slide.

Year	Approved N (%)	Denied N (%)	Total	
2021	630 (92%)	54 (8%)	684	
2020	587 (98%)	14 (2%)	601	
2019	763 (99%)	11 (1%)	774	
2018	773 (96%)	29 (4%)	802	
Grand Total	2753 (96%)	108 (4%)	2861	

*Data reflects the time period 2018 – 2021 and is based on volume of Prior Authorization decision letters sent to members. 
**Doesn’t reflect volume of DME approved without requiring Prior Authorization (PA), as letters are only sent for services requiring it

Slide 6: DME Letters* – Rating Category
The majority of DME requests are driven by C3 members, with requests from C2 members also fairly common.
•	C1: 14%
•	C2: 31%
o	C2A: 26%
o	C2B: 6%  
•	C3: 53%
o	C3A: 49%
o	C3B: 4%
•	F1: 2%

Note: the following is shown in a bar chart on this slide.

DME Requests by Year and Rating Category

2018
C1	110
C2	283
C3	444
F1	40

2019
C1	136
C2	306
C3	489
F1	15

2020
C1	130
C2	257
C3	446
F1	10

2021
C1	113
C2	282
C3	510
F1	10

*Letters are sent for DME requiring prior authorization
Slide 7: DME Letters1 – Year and Rating Category
Note: the following is shown in a bar chart on this slide. The percentages listed are approximate.

2018
C1 N = 101, Approval 98%, Denial 2%
C2 N = 261, Approval 98%, Denial 2%
C3 N = 400, Approval 97%, Denial 3%
F1 N = 36, Approval 98%; Denial 2%

2019
C1 N = 103, Approval 100%, Denial 0%
C2 N = 249, Approval 100%, Denial 0%
C3 N = 407, Approval 98%, Denial 2%
F1 N = 14, Approval 94%, Denial 6%

2020
C1 N = 86, Approval 97%, Denial 3%
C2 N = 173, Approval 99%, Denial 1%
C3 N = 331, Approval 98%, Denial 2%
F1 N = 5, Approval 100%, Denial 0%

2021
C1 N = 83, Approval 88%, Denial 12%
C2 N = 208, Approval 95%, Denial 5%
C3 N = 381, Approval 92%, Denial 8%
F1 N = 7, Approval 100%, Denial 0%

*Letters are sent for DME requiring prior authorization
Slide 8: Appendix
Slide 9: UM Decision Letter Examples: Approval
Identifies and describes all services for which the member has been approved

Slide 10: UM Decision Letter Examples: Partial Approval or Denial
Outlines why the service was approved with modifications or denied, including several pages describing how the member may appeal the decision