Common use of Service Authorization Policies and Procedures Clause in Contracts

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 and procedures which shall include, but are not limited to, the following: Policies and procedures to automatically authorize at least twelve (12) Behavioral Health Outpatient Services; Policies and procedures for the authorization of all Behavioral Health Outpatient Services beyond the initial twelve (12) Outpatient Services; Policies and procedures to authorize Behavioral Health Outpatient Services based upon Behavioral Health Clinical Criteria; and Policies and procedures based upon Behavioral Health Clinical Criteria; to review and approve or deny all requests for Behavioral Health Outpatient Services based on Clinical Criteria. Coordinating Access for Emergency Conditions and Urgent Care Services The Contractor must ensure linkages among the ICT, and any appropriate acute, LTSS, pharmacy or Behavioral Health Providers to keep all parties informed about utilization of services for Emergency Medical Conditions and Urgent Care. Authorization of LTSS, Expanded Services, and Community-based Services At a minimum, the Contractor‘s authorizations of LTSS listed in Appendix B, Exhibit 1, must comply with MassHealth FFS authorization criteria for those Covered Services. The Contractor must develop authorization criteria and a process for authorizing the expansions of PCA and DME services listed in Appendix B, Exhibit 3 that considers the Enrollee‘s entire ICP. The Contractor has the discretion to authorize such services in a determined amount, duration and scope for an Enrollee, if the Contractor 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 ICP, considering how the services contribute to the health and independent living of the Enrollee in the least restrictive setting and with reduced reliance on emergency department use, acute inpatient care and institutional long-term care. The Contractor must develop authorization criteria and a process for authorizing the Community-based Services listed in Appendix B, Exhibit 4 that considers the Enrollee‘s entire ICP. The Contractor has the discretion to authorize such services in a determined amount, duration and scope for an Enrollee if the Contractor 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 ICP, considering how the services contribute to the health and independent living of the Enrollee in the least restrictive setting and with reduced reliance on emergency department use, acute inpatient care and institutional long-term care. The Contractor has discretion to cover other community-based services not listed in Appendix B if the Contractor determines that such authorization would provide sufficient value to the Enrollee‘s care, considering the Enrollee‘s entire ICP. Value shall be determined in light of the full range of services included in the ICP, considering how the services contribute to the health and independent living of the Enrollee in the least restrictive setting and with reduced reliance on emergency department use, acute inpatient care and institutional long-term care.

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 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- 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 and procedures which shall include, but are not limited to, the following: Policies and procedures to automatically authorize at least twelve (12) Behavioral Health Outpatient Services; Policies and procedures for the authorization of all Behavioral Health Outpatient Services beyond the initial twelve (12) Outpatient Services; Policies and procedures to authorize Behavioral Health Outpatient Services based upon Behavioral Health Clinical Criteria; and Policies and procedures based upon Behavioral Health Clinical Criteria; to review and approve or deny all requests for Behavioral Health Outpatient Services based on Clinical Criteria. Coordinating Access for Emergency Conditions and Urgent Care Services The Contractor must ensure linkages among the ICT, and any appropriate acute, LTSS, pharmacy or Behavioral Health Providers to keep all parties informed about utilization of services for Emergency Medical Conditions and Urgent Care. Authorization of LTSS, Expanded Services, and Community-based Services At a minimum, the Contractor‘s Contractor’s authorizations of LTSS listed in Appendix B, Exhibit 1, must comply with MassHealth FFS authorization criteria for those Covered Services. The Contractor must develop authorization criteria and a process for authorizing the expansions of PCA and DME services listed in Appendix B, Exhibit 3 that considers the Enrollee‘s Enrollee’s entire ICP. The Contractor has the discretion to authorize such services in a determined amount, duration and scope for an Enrollee, if the Contractor determines that such authorization would provide sufficient value to the Enrollee‘s Enrollee’s care. Value shall be determined in light of the full range of services included in the ICP, considering how the services contribute to the health and independent living of the Enrollee in the least restrictive setting and with reduced reliance on emergency department use, acute inpatient care and institutional long-term care. The Contractor must develop authorization criteria and a process for authorizing the Community-based Services listed in Appendix B, Exhibit 4 that considers the Enrollee‘s Enrollee’s entire ICP. The Contractor has the discretion to authorize such services in a determined amount, duration and scope for an Enrollee if the Contractor determines that such authorization would provide sufficient value to the Enrollee‘s Enrollee’s care. Value shall be determined in light of the full range of services included in the ICP, considering how the services contribute to the health and independent living of the Enrollee in the least restrictive setting and with reduced reliance on emergency department use, acute inpatient care and institutional long-term care. The Contractor has discretion to cover other community-based services not listed in Appendix B if the Contractor determines that such authorization would provide sufficient value to the Enrollee‘s Enrollee’s care, considering the Enrollee‘s Enrollee’s entire ICP. Value shall be determined in light of the full range of services included in the ICP, considering how the services contribute to the health and independent living of the Enrollee in the least restrictive setting and with reduced reliance on emergency department use, acute inpatient care and institutional long-term care.