Authorization of LTSS. 2.8.3.9.1.The STAR+PLUS MMP must develop an authorization process for the LTSS listed in Appendix A.
Authorization of LTSS. 2.11.6.1. The Contractor must develop an authorization process for the LTSS listed in Appendix B.
Authorization of LTSS. 2.8.5.1. The ICO must develop an authorization process for the LTSS listed in Appendix A.
Authorization of LTSS. The ICO must develop an authorization process for the LTSS listed in Appendix A. At a minimum, the ICO’s authorization of LTSS must comply with MDHHS’s FFS authorization criteria for those Covered Services. However, the ICO has the discretion to authorize LTSS more broadly in terms of criteria, amount, duration and scope, if the IICSP determines that such authorization would provide sufficient value to the Enrollee’s care. Value shall be determined in light of the full range of services included in the IICSP, considering how the services contribute to the health and independent living of the Enrollee in the most integrated and least restrictive setting with reduced reliance on emergency department use, acute inpatient care and institutional LTSS. The ICO shall be responsible for payment for any PCS and HCBS waiver services authorized and provided to an Enrollee during a period of active Enrollment. If an Enrollee is retroactively disenrolled from the ICO after a PCS and/or HCBS service has been authorized and delivered, the ICO must pay for the service. Recoupment from providers for PCS and HCBS services authorized and delivered is prohibited. Utilization Management The ICO’s UM programs shall comply with CMS requirements and timeframes for historically Medicare primary paid services in addition to the requirements for historically Medicaid primary paid services. No sooner than January 1, 2024, ICO shall have a UM committee that meets the requirements set forth at 42 C.F.R. § 422.137. The ICO must have a written UM program description which includes procedures to evaluate medical necessity, criteria used, information source, and the process used to review and approve or deny the provision of medical and long-term care services. The ICO’s UM program must ensure consistent application of review criteria for authorization decisions; and must consult with the requesting provider when appropriate. The program shall demonstrate that Enrollees have equitable access to care across the network and that UM decisions are made in a fair, impartial, and consistent manner that serves the best interests of the Enrollees. The program shall reflect the standards for UM from the most current NCQA standards when applicable. The program must have mechanisms to detect under-utilization and/or over-utilization of care including, but not limited to, provider profiles. If the ICO delegates responsibilities for UM to a First Tier, Downstream or Rel...
