Service Authorization Policies and Procedures a. Services in the Long-Term Care Benefit Package The MCO may use the Resource Allocation Decision Method (RAD) as its service authorization policy. If the MCO does not use the RAD, it must seek Department approval of alternative service authorization policies and procedures. The policies and procedures must address how new and continuing authorizations of services are approved and denied. The MCO may choose to create decision-making guidelines for more frequently used items and/or services. When the MCO wishes to utilize these guidelines as part of the RAD or alternative service authorization documentation (instead of documenting evidence), the guidelines must be approved by the Department.
Service Authorization Policies and Procedures. Services in the Long-Term Care Benefit Package The MCO may use the Resource Allocation Decision Method (RAD) as its service authorization policy. If the MCO does not use the RAD, it must seek Department approval of alternative service authorization policies and procedures. The policies and procedures must address how new and continuing authorizations of services are approved and denied. The MCO may choose to create decision-making guidelines for more frequently used items and/or services. When the MCO wishes to utilize these guidelines as part of the RAD or alternative service authorization documentation (instead of documenting evidence), the guidelines must be approved by the Department. Services shall be authorized in a manner that reflects the member’s ongoing need for such services and supports as determined through the comprehensive assessment and consistent with the member-centered plan. Acute and Primary Care Services in the Partnership Benefit Package The MCO shall have documented and Department-approved service authorization policies and procedures for services in the acute and primary care benefit package. Policies and procedures may differ from the authorization policies and procedures for services in the long-term care benefit package, and may be based on accepted clinical practices. Decisions about the authorization of services in the acute and primary care benefit package may be made outside of the IDT by other clinical professionals with consideration for member preferences. Authorization of Services in Partnership Dual Eligibles SNPs The MCO shall coordinate and authorize the delivery of covered Medicare, Medicaid, and long-term care services using aligned care management by first using Medicare coverage and authorization policies, procedures and requirements. If the MCO determines that Medicare will not cover the service, the MCO must then use and follow the Medicaid coverage rules, including the RAD, to determine if Medicaid will cover the service.
Service Authorization Policies and Procedures. The Contractor shall: Review and update annually, at a minimum, the Behavioral Health Clinical Criteria and other clinical protocols that the One Care Plan may develop and utilize in its review and submit any modifications to EOHHS annually for review and approval. In its review and update process, the Contractor shall consult with its clinical staff or medical consultants outside of the Contractor‘s organization, or both, who are familiar with standards and practices of mental health and substance use treatment in Massachusetts. Review and update annually and submit for EOHHS approval, at a minimum, its Behavioral Health Services authorization policies and procedures. Develop and maintain Behavioral Health Inpatient Services and Diversionary Services authorization policies and procedures, which shall, at a minimum, contain the following requirements: If prior authorization is required for any Behavioral Health Inpatient Services admission or Diversionary Service, assure the availability of such prior authorization twenty- four (24) hours a day, seven (7) days a week; A plan and a system in place to direct Enrollees to the least intensive but clinically appropriate service; A system to provide an initial authorization and communicate the initial authorized length of stay to the Enrollee, facility, and attending physician for all Behavioral Health emergency inpatient admissions verbally within thirty (30) minutes, and within two (2) hours for non-emergency inpatient authorization and in writing within twenty-four (24) hours of admission; Processes to ensure placement for Enrollees who require Behavioral Health Inpatient Services when no inpatient beds are available, including methods and places of care to be utilized while Enrollee is awaiting an inpatient bed; A system to concurrently review Behavioral Health Inpatient Services to monitor Medical Necessity for the need for continued stay, and achievement of Behavioral Health Inpatient Services treatment goals; Verification and authorization of all adjustments to Behavioral Health Inpatient Services treatment plans and Diversionary Services treatment plans; and Processes to ensure that treatment and discharge needs are addressed at the time of authorization and concurrent review, and that the treatment planning includes coordination with the PCP and other providers, such as community-based mental health services providers, as appropriate; Develop and maintain Behavioral Health Outpatient Services policies a...
Service Authorization Policies and Procedures. Decisions by the interdisciplinary team to provide or deny services must be based on an evaluation of the participant that takes into account: The participant's current medical, physical, emotional, and social needs; and Current clinical practice guidelines and professional standards of care applicable to the particular service. Long-Term Care Services The PO may use the Resource Allocation Decision Method (RAD) as its service authorization policy. If the PO does not use the RAD, it must seek Department approval of alternative service authorization policies and procedures. The policies and procedures must address how new and continuing authorizations of services are approved and denied. The PO may choose to create decision-making guidelines for more frequently used items and/or services. When the PO wishes to utilize these guidelines as part of the RAD or alternative service authorization documentation (instead of documenting evidence), the guidelines must be approved by the Department. Services shall be authorized in a manner that reflects the member’s ongoing need for such services and supports as determined through the comprehensive assessment and consistent with the member-centered plan. Acute and Primary Care Services The PO shall have documented and Department-approved service authorization policies and procedures for acute and primary care services. Policies and procedures may differ from the authorization policies and procedures for long-term care services and may be based on accepted clinical practices. Decisions about the authorization of acute and primary care services may be made outside of the IDT by other clinical professionals with consideration for member preferences. Authorization of Medicare Services PACE organizations in making authorization decisions about services in PACE shall first use and follow Medicare coverage and authorization policies, procedures and requirements rather than the RAD or other Department-approved service authorization policies and procedures used for the authorization of Medicaid services under this contract. If the PO determines that Medicare will not cover the service, the PO must then use and follow the Medicaid coverage rules, including the RAD, to determine if Medicaid will cover the service.
Service Authorization Policies and Procedures e. Remote Waiver Services and Interactive Telehealth
Service Authorization Policies and Procedures a. Services in the Long-Term Care Benefit Package For the services in the long-term care benefit package the MCO shall have documented and Department-approved service authorization policies and procedures for processing requests for initial and continuing authorizations of services and for determining approval or denial of services. The MCO may use the Resource Allocation Decision Method (RAD), as developed and disseminated by the Department. If the MCO does not use the RAD, it must seek Department approval of alternative service authorization policies and procedures. The MCO may use the RAD as its general service authorization policy and seek approval for authorization policies and procedures that it will use for specified services or items.
Service Authorization Policies and Procedures a. Services in the Long-Term Care Benefit Package The IHCP must use the MCO’s electronic care management system to generate service authorizations and must follow the MCO’s DHS-approved service authorization policy and procedures.
Service Authorization Policies and Procedures a. Decisions by the interdisciplinary team to provide or deny services must be based on an evaluation of the participant that takes into account: The participant's current medical, physical, emotional, and social needs; and Current clinical practice guidelines and professional standards of care applicable to the particular service.
Service Authorization Policies and Procedures. Services in the Long-Term Care Benefit Package The IHCP must use the MCO’s electronic care management system to generate service authorizations and must follow the MCO’s DHS- approved service authorization policy and procedures. Procedures IDT staff shall use the MCO’s DHS-approved standardized service authorization policies, procedures and guidelines, as applicable. IDT staff shall explain to the member the standardized service authorization process (RAD process), the member’s role and responsibilities in that process, and when the service authorization process is being used. The IHCP must have in effect mechanisms to ensure consistent applications of review criteria for authorization decisions; and consult with the requesting provider when appropriate.
Service Authorization Policies and Procedures
