County Data Nothing in this Agreement will be construed to waive the requirements of § 205.009 of the Texas Local Government Code.
County Obligations 27 A. COUNTY shall provide oversight of the MSI Program, including appropriate program 28 administration, coordination, planning, evaluation, financial and contract monitoring, public information 29 and referral, standards assurance, and review and analysis of data gathered and reported. 30 B. COUNTY shall establish either directly and/or through subcontract(s), a Utilization 31 Management Department (UMD) which shall: 32 1. Coordinate and make arrangements for the medical needs and care of MSI Eligibles. The 33 UMD shall not be responsible for the coordination of social services needs of such patients. 34 2. Perform concurrent and retrospective utilization review of the medical appropriateness, 35 level of care, and utilization of all services provided to MSI Patients by All Providers. The parties 36 understand that the UMD shall use the latest available version of the Milliman Continuum of Care 37 Criteria as its guideline for such utilization review. COUNTY acknowledges that HOSPITAL may use 1 Interqual criteria for similar purposes within its own operations and with this understanding: 2 // 3 // 4 a. Prior to recommendation of denial of any inpatient day provided by HOSPITAL that 5 does not meet Milliman criteria, the UMD shall notify HOSPITAL of a pending denial recommendation 6 within two (2) business days of such determination. 7 b. HOSPITAL shall have the opportunity to provide written justification, within two (2) 8 business days after receiving written notice of recommended denial, to the UMD which justification 9 may include the application of Interqual criteria and/or other supporting information, as HOSPITAL 10 deems necessary. 11 c. If the UMD subsequently recommends denial of the inpatient day, HOSPITAL shall 12 have the right to appeal the decision to the Medical Review Committee as specified in Paragraph V. of 13 this Exhibit A to the Agreement. 14 3. Communicate with HOSPITAL regarding diversions, admissions, and discharge planning. 15 4. Assist in coordinating the transitions of MSI Patients to appropriate outpatient care, lower 16 levels of care or needed services through COUNTY contracted providers for skilled nursing facilities, 17 durable medical equipment and pharmacy services and through community-based providers for home 18 health care. 19 5. Conduct patient, HOSPITAL, and Other Provider education which shall include, but not be 20 limited to: 21 a. Availability of MSI Program services at locations other than UCI Medical Center. 22 b. MSI Program services available at Community Clinics 23 c. Services for which pre-authorization is recommended through the UMD. 24 C. Upon mutual written agreement, COUNTY may enter into separate agreements for Sub-Acute 25 Services for MSI Eligibles or MSI Patients. Execution of such agreements shall be contingent upon 26 mutual written agreement regarding the definition of sub-acute services, implementation, and payment 27 procedures. 28 D. ADMINISTRATOR may negotiate additional Points for patient-specific specialized outpatient 29 services provided by certain Contracting Hospitals as specified by the MSI Program Medical Director, 30 and authorized in writing by ADMINISTRATOR, at a number of Points negotiated by