MMO's Medical Policies and Review Process

It is important that practices make themselves aware of relevant medical policies to ensure timely reimbursement. While no one practice will be able to keep track of all the medical policies of all the plans they participate in, most insurers, including Medical Mutual of Ohio (MMO), offer web access to their policies.

To access MMO’s Medical policies online click here.

Medical Mutual’s extensive Corporate Medical Policies (CMP) address medical necessity, technology assessment and a long list of other issues. There are nearly 200 procedures, therapies, technologies or devices currently covered in MMO’s Corporate Medical Policies. These include such diverse topics as bariatric surgery, facial muscle surgery, carotid artery stenting, and intrauterine fetal surgery. MMO’s policy descriptions also include specific clinical criteria that must be met for services to be considered medically necessary. MMO utilizes a variety of physicians with specialized qualifications to consult on the development of a medical policy in emerging specialty areas. Medical Policies are organized by subject matter and are cross-referenced by specific CPT codes. The list includes both the initial policy development date and the most recent review date. Each individual policy includes the pertinent CPT codes, a review of the procedure/protocol/technology and the clinical criteria for medical necessity.

To access MMO’s medical necessity guidelines click here.

To access MMO’s list of clinical guidelines click here.

Medical Necessity Review Process

Medical Mutual refers to the process of determining medical necessity as “Prior Approval.” MMO indicates that its decisions are based upon the facts of each situation presented using Corporate Medical Policies as a guideline.

When a request for prior approval is received, it is initially reviewed by a licensed nurse. The nurse reviewer has the ability to approve the service, but does not have the authority to issue a denial of service. If the MMO nurse determines that its medical necessity guidelines are not met, he or she forwards the case to one of Medical Mutual’s physician advisors. These physician advisors are not employees of Medical Mutual. They are practicing physicians representing a variety of specialties. Most reviews are conducted by a single physician reviewer. The requesting physician and the covered person are notified by MMO of the review determination. If the service is not approved, a letter will be sent explaining the denial reason(s), the specific criteria used, and how to reach a physician advisor to discuss the reconsideration of the initial denial decision, as well as information on appeal rights and process.

The attending physician may contact MMO within 10 days to ask for reconsideration, which is then carried out via peer-to-peer interaction with a physician adviser. All reconsideration requests are handled through MMO’s Care Management Department at (800) 338-2873. MMO recommends that when calling for reconsideration, physicians should use the “priority” option listed in the phone menu. If the physician is not satisfied with the outcome of the reconsideration, an appeal may be filed as described in the initial denial letter.