Adverse Determination Dossier Agent
Builds the clinician-ready decision packet and the draft notice for every case heading toward a non-approval.
Everything it produces is addressed to a doctor. A proton-therapy request in Texas heading for a non-approval gets a record extract, the criteria version applied, the clinical facts that failed, and a reviewer requirement of Texas licensure in the same or a similar specialty. The stated reason on the notice is a clinical fact, never a criteria label, and the physician signs.
Authority
Prepare
Team role
Completes a defined task
Handoffs
Named collaborators
The role
What it owns and where its authority ends
Desk
Utilization Management & Prior Authorization
Desk workflow
Take the request on whatever channel it arrives, start the correct clock under the correct rulebook, assemble the clinical packet and rank the governing criteria, let the approvals that sit inside explicit criteria go out under licensed supervision, route everything else to a physician or appropriate clinical peer with the dossier and draft notice already built, then audit the whole path for any request that ended without one.
Collaboration
Moves work through defined stages
Decision boundary
Assembles the work product; approval remains elsewhere.
Systems and capabilities involved
MHK determination and notice workflow
CMS-10003-NDMCP notice templates
The Integrated Denial Notice form set for Medicare Advantage, with the ACA and Medicaid content rules alongside.
Reviewer credential and state licensure register
InterQual Decision Reasons
Member-readable rationale language, used as raw material for the notice rather than as the reason itself.
Specialty-matched physician reviewer
Handoffs
What this role gives and receives
Capabilities offered
Determination dossier and draft notice
Assembles the record, criteria basis and failed elements into a reviewer packet, drafts the notice, and names the credential the reviewer must hold.
- Receives:
- Criteria finding, case record, member line of business, state of service, and prior reviewer ledger
- Returns:
- Reviewer packet, draft notice with specific reason and appeal rights, credential requirement, and peer-to-peer log entry
Handoff to
Handoff to
Receives from
Receives from
Receives from
External handoff
Plan medical director
External handoff
Contracted specialty physician reviewer
External handoff
Treating practitioner
Context
What the role needs to do the work
- Current work
- Record extract, criteria version and failed elements, required reviewer credential, draft notice text, and the remaining clock.
- Prior interactions
- Who touched this case, in what role, with what credential, including anyone consulted on an earlier determination.
- Policies and reference
- Notice content rules by line of business, state reviewer-qualification law, and the credential map for each denial type.
- Working method
- Peer-to-peer offer and logging standard, and the reconsideration non-involvement check.
Illustrative workflow
How the work moves
Starting point
A proton beam therapy request for a Texas member with a base-of-skull tumor fails the plan's criteria for the requested modality.
- 01
Assemble the pathology, imaging, prior radiation history and the comparative dose plan the oncology office submitted.
- 02
Derive the reviewer requirement: a Texas-licensed radiation oncologist of the same or similar specialty under 28 Tex. Admin. Code 19.1732(b).
- 03
Draft the notice with the clinical facts that failed, the criteria source and version, member-readable rationale and appeal rights.
- 04
Log the peer-to-peer offer with method, name and timestamp into the denial file, and set the deadline alarm to fire whether or not the treating oncologist calls back.
Result
A dossier and draft notice staged for the specialty-matched physician reviewer, who forms the judgment, decides, and signs the determination.
Checks and boundaries
What must be tested or reviewed
- 01Notice-sufficiency audit on sampled drafts: each must carry a specific clinical reason, the criteria set and version applied, the facts that failed, member-readable rationale, and complete appeal rights, scored against 42 CFR 422.122(a), the CMS-10003-NDMCP instructions and the ACA content rules.
- 02Reviewer-match check: the required credential is derived for every packet (physician, nurse practitioner where the practice act allows, pharmacist, doctoral-level psychologist, addiction-medicine specialist, physical therapist or behavior analyst), together with any state specialty and in-state licensure requirement.
- 03Reconsideration non-involvement replay: given a who-touched-this ledger, a proposed reviewer who worked the original determination, or who reports to whoever did, is refused with the conflict named.
- 04A pending peer-to-peer never consumes the determination clock, and a criteria label never stands in for the specific reason the notice requires.
Human authority
- The plan medical director or the specialty-matched physician reviewer forms the clinical judgment and signs the determination; the packet carries no authority of its own.
- On reconsideration a physician not involved in the original determination, and not a subordinate of anyone who was, takes the case.
- The treating practitioner holds the peer-to-peer opportunity, which is a conversation and not an appeal.
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