Aetna US Healthcare	BCBSNC	CIGNA/ Healthsource	Doctors Health Plan	Generations	Optimum Choice of the Carolinas	PARTNERS Health Plans
Utilization Review Information Data From NC Department of Insurance (Utilization review, Appeal and Grievance Reports)
Number of reviews (1999)	11,440	1,317,448	78,217	27,824	6,712	3,857	62,634
Review rate per 1,000 members	203	9,172	444	820	527	380	204
Number of noncertifications, 1999	869	2695	5367	892	325	213	5529
Percentage of noncertifications, 1999	7.6%	.16%	6.86%	3.21%	4.84%	5.52%	8.83%
Noncertification rates per 1,000 members	15	14	30	26	26	21	18
Appeal Rate per 1,000 Noncertifications	146.14	42.30	208.12	39.24	30.77	56.34	88.99
Percentage non-certification appeals and 2nd level grievances decided in member’s favor	57.81%	46.616%	64.73%	23.68%	50%	38.46%	30.30%

	Coventry/Principal Health Care of the Carolinas	QualChoice	The Wellness Plan of North Carolina, Inc.	United Healthcare of NC	WellPath Select
Utilization Review Information Data From NC Department of Insurance (Utilization Review, Appeal and Grievance Reports)
Number of reviews (1998)	9,509	24,560	41,759	110,365	44,614
Review rate per 1,000 members	197	336	517	420	394
Number of Noncertifications, 1998	521	393	1429	7127	1971
Percentage of noncertifications, 1998	5.48%	1.50%	3.42%	6.46%	4.42%
Noncertification rates per 1,000 members	11	5	18	27	17
Appeal Rate per 1,000 Noncertifications	34.55	53.44	36.39	15.29	137.49
Percentage non-certification appeals and 2d-level grievances decided in member’s favor	10.53%	23.81%	73.85%	34.82%	20.22%

How To Read Utilization Review Information

• Number of Reviews. This lists the number of health services, procedures or tests that the HMO reviewed in 1998. Utilization review includes requests for prospective reviews (e.g., precertification or prior authorization requirements), concurrent review (e.g., hospital length of stay reviews) and retrospective reviews. HMOs are required to report data separately for inpatient, outpatient, specialty, pharmacy, mental health inpatient, mental health outpatient, some emergency services, and other reviews. The number of reviews should be read with some caution. The HMOs may not be reporting their data consistently. For example, Blue Cross Blue Shield appears to have an internal mechanism to report all (or most) of its claims for internal quality assurance purposes. Therefore, BCBSNC appears to have an abnormally large number of reviews (and review rate per 1,000 members). The NC Department of Insurance hopes to develop reporting guidelines in the future which should improve the consistency of the data reported across plans.
  
  
• Review rate per 1,000 members. This gives the average number of procedures that the HMOs reviewed per member in 1998. We calculated the average review rate per 1,000 members by taking the total number of reviews, dividing it by the average number of members reported to the NC Department of Insurance and multiplying this by 1000. For example, a review rate of 200 means that the HMO reviewed 200 procedures for every 1,000 members. The review rate can help identify HMOs with more stringent utilization review systems. The HMOs with the higher rates review health care services, tests and procedures more often than those with lower review rates. The utilization review rate only describes the frequency that health care procedures are subject to review. The review rate does not describe whether the reviews were approved or denied. The review rates per 1,000 members should be read with some caution. The HMOs may not be reporting their data consistently. For example, Blue Cross Blue Shield appears to have an internal mechanism to report all (or most) of its claims for internal quality assurance purposes. Therefore, BCBSNC appears to have an abnormally large number of reviews (and review rate per 1,000 members). The NC Department of Insurance hopes to develop reporting guidelines in the future which should improve the consistency of the data reported
  
  
• Number of Noncertifications: This number is the number of service denials in 1998. It is important to remember that HMOs deny services for many reasons. Some HMOs deny health care services because there are other services that can better meet the health care needs of the patient. Other HMOs deny services because they have stricter standards about what they consider appropriate health care services. Comparing denial rates across HMOs can help identify HMOs that are more likely to deny requested services. However, these rates will not show how the HMO will handle your particular medical needs. The noncertification numbers should be read with some caution. The HMOs may not be reporting their data consistently. For example, there are some indications that some HMOs did not include all the denials of emergency services in their non-certification numbers. This would make their number of noncertifications appear smaller than the HMOs that do report all emergency room service demands.The NC Department of Insurance hopes to develop reporting guidelines in the future which should improve the consistency of the data reported.
  
  
• Percentage of Non-Certifications. This is the percentage of all reviews that are denied by the health plan. It is important to look at both the utilization review rates (see above) and the denial rates (percentage of non-certification). An HMO that does not require prior authorization for most procedures may have a low review rate. However, it may have a higher denial rate as it limits the reviews to the services that are more likely to be denied. Another HMO may have a high review rate, but a lower denial rate. While review and non-certification rates can identify plans with more or less stringent utilization review systems, these rates will not show how the HMO will handle your particular medical needs. The percentages of non-certifications should be read with some caution. The HMOs may not be reporting their data consistently. For example, there are some indications that some HMOs did not include all the denials of emergency services in their non-certification numbers. The NC Department of Insurance hopes to develop reporting guidelines in the future which should improve the consistency of the data reported
  
  
• Non-Certification rates. This is the average number of service denials per 1,000 members in 1998. We calculated the average non-certification (denial) rate per 1,000 members by taking the total number of denials, dividing it by the average number of members reported to the NC Department of Insurance and multiplying this by 1,000. Thus, a denial rate of 20 means that the HMO denied 20 services for every 1,000 members. It is important to remember that HMOs deny services for many reasons. Some HMOs deny health care services because there are other services that can better meet the health care needs of the patient. Other HMOs deny services because they have stricter standards about what they consider appropriate health care services. Comparing denial rates across HMOs can help identify HMOs that are more likely to deny requested services. However, these rates will not show how the HMO will handle your particular medical needs. The non-certification rates should be read with some caution. The HMOs may not be reporting their data consistently. For example, there are some indications that some HMOs did not include all the denials of emergency services in their non-certification numbers. The NC Department of Insurance hopes to develop reporting guidelines in the future which should improve the consistency of the data reported.
  
  
• Appeal Rate per 1,000 Noncertifications. This is the average number of appeals for every 1,000 noncertifications. We calculated this number by dividing the number of first level appeals by the total number of noncertifications and then multiplying that number by 1,000. This appeal rate does not included second level grievances. The appeal rate may be higher if a plan has a low number of noncertifications. See "Number of Noncertifications" section to obtain the number of noncertifications for each plan.
  
  
• Percentage of Appeals Decided for the Members. This shows the percentage of appeals that were decided in favor of the member. While the success rate varies among HMOs, more than half of the appeals that patients filed last year were decided on behalf of the member. Part of the reason is that the members or their providers provided additional medical information which showed why the requested health services were appropriate. This data does not include the number of decisions that were pending at the time the numbers were reported.

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