Section 8 – Utilization Management Clause Samples
Section 8 – Utilization Management establishes the procedures and criteria by which a health plan or insurer reviews and approves the use of healthcare services, treatments, or medications. This clause typically outlines the process for prior authorization, concurrent review, and retrospective review to determine whether services are medically necessary and covered under the plan. By setting these standards, the clause helps control healthcare costs, ensures appropriate use of resources, and provides clarity to both providers and members regarding coverage decisions.
Section 8 – Utilization Management. (3 pages, plus 1 additional page for each additional MCO Program bid if the Respondent’s response differs by MCO Program) Utilization Management (UM) requirements are described generally in Section 8.1.8 and specifically for Behavioral Health Services in Section 8.1.15. A Respondent’s response to this submission requirement should address UM for all Covered Services.
1. Describe the UM guidelines the Respondent plans to employ, including whether and how the guidelines comply with the standards in Sections 8.1.8 and 8.1.15.
2. If the UM guidelines were developed internally, describe the process by which they were developed and when they were developed or last revised.
3. Describe how the UM guidelines will generally be applied to authorize or retrospectively review services for the spectrum of Covered Services. If a Respondent is submitting a multi-program response to this RFP, the Respondent should note in its Proposal the differences, if any, in its UM activities for each MCO Program bid.
Section 8 – Utilization Management. (3 pages, plus 1 additional page for each additional MCO Program bid if the Respondent’s response differs by MCO Program) Utilization Management (UM) requirements are described generally in Section 8.1.8 and specifically for Behavioral Health Services in Section 8.1.15. A Respondent’s response to this submission requirement should address UM for all Covered Services.