Utilization Management Program. The Contractor shall implement a Utilization Management (UM) Program that meets the requirements set forth in this section and that is documented in a plan as defined in KRS 304.17A- 600. The UM program, processes and timeframes shall be in accordance with 42 C.F.R. 456, 42 C.F.R. 431, 42 C.F.R. 438. If the Contractor utilizes a private review agent, as defined in KRS 304.17A-600, the agent shall comply with all applicable requirements of KRS 304.17A-600 to 304.17A-633, as applicable. The Medical Director and Behavioral Health Director shall supervise the UM Program and shall be accessible and available for consultation as needed. The Contractor shall implement innovative and effective Utilization Management processes to ensure a high quality, clinically appropriate yet highly efficient and cost-effective delivery system. The Contractor shall continually evaluate the cost and quality of medical services delivered by Providers. The Contractor shall apply objective and evidence-based criteria that take the individual Enrollee’s circumstances when determining the Medical Necessity of health care services. The Contractor shall have a written plan for the UM program that details the program structure and, if delegated, includes a clear definition of authority and accountability for all activities between the Contractor and entities to which the Contractor delegates UM activities. The UM Program and Review Plan shall comply with KRS 304.17A-600 and include the following information, at a minimum: A. Scope of the program; B. The processes and information sources used to determine service coverage; C. List which services require PCP Referral; which services require Prior Authorization and how requests for initial and continuing services are processed; D. Written policies and procedures to evaluate Medical Necessity, the criteria used, information sources, timeframes and the process used to review, approve, or deny the provision of services, as needed, including those specific to the EPSDT program; E. Policies and procedures to evaluate discharge criteria, site of services, levels of care, triage decisions and cultural competence of care delivery; F. Written policies and procedures for monitoring to ensure clinically appropriate overall continuity of care; G. Written policies to ensure the coordination of services: 1. Between settings of care, including appropriate Discharge Planning for short-term and long-term hospital and institutional stays; 2. With the services the Enrollee receives from any other MCO; 3. With the services the Enrollee receives in FFS; and 4. With the services the Enrollee receives from community and social support providers. H. Written policies and procedures that explain how Prior Authorization data shall be incorporated into the Contractor’s overall Quality Improvement Plan; I. Education plan for UM Program staff in the application of related policies and use of designated criteria in making UM decisions; J. Written policies and procedures for complying with the Mental Health Parity And Addiction Equity Act (MHPAEA);
Appears in 3 contracts
Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract, Medicaid Managed Care Contract
Utilization Management Program. The Contractor shall implement a Utilization Management (UM) Program that meets the requirements set forth in this section and that is documented in a plan as defined in KRS 304.17A- 600. The UM program, processes and timeframes shall be in accordance with 42 C.F.R. 456, 42 C.F.R. 431, 42 C.F.R. 438. If the Contractor utilizes a private review agent, as defined in KRS 304.17A-600, the agent shall comply with all applicable requirements of KRS 304.17A-600 to 304.17A-633, as applicable. The Medical Director and Behavioral Health Director shall supervise the UM Program and shall be accessible and available for consultation as needed. The Contractor shall implement innovative and effective Utilization Management processes to ensure a high quality, clinically appropriate yet highly efficient and cost-effective delivery system. The Contractor shall continually evaluate the cost and quality of medical services delivered by Providers. The Contractor shall apply objective and evidence-based criteria that take the individual Enrollee’s circumstances when determining the Medical Necessity of health care services. The Contractor shall have a written plan for the UM program that details the program structure and, if delegated, includes a clear definition of authority and accountability for all activities between the Contractor and entities to which the Contractor delegates UM activities. The UM Program and Review Plan shall comply with KRS 304.17A-600 and include the following information, at a minimum:
A. Scope X. Xxxxx of the program;
B. The processes and information sources used to determine service coverage;
C. List which services require PCP Referral; which services require Prior Authorization and how requests for initial and continuing services are processed;
D. Written policies and procedures to evaluate Medical Necessity, the criteria used, information sources, timeframes and the process used to review, approve, or deny the provision of services, as needed, including those specific to the EPSDT program;
E. Policies and procedures to evaluate discharge criteria, site of services, levels of care, triage decisions and cultural competence of care delivery;
F. Written policies and procedures for monitoring to ensure clinically appropriate overall continuity of care;
G. Written policies to ensure the coordination of services:
1. Between settings of care, including appropriate Discharge Planning for short-term and long-term hospital and institutional stays;
2. With the services the Enrollee receives from any other MCO;
3. With the services the Enrollee receives in FFS; and
4. With the services the Enrollee receives from community and social support providers.
H. Written policies and procedures that explain how Prior Authorization data shall be incorporated into the Contractor’s overall Quality Improvement Plan;
I. Education plan for UM Program staff in the application of related policies and use of designated criteria in making UM decisions;
J. Written policies and procedures for complying with the Mental Health Parity And Addiction Equity Act (MHPAEA);
Appears in 2 contracts
Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract
Utilization Management Program. The Contractor shall implement a Utilization Management (UM) Program that meets the requirements set forth in this section and that is documented in a plan as defined in KRS 304.17A- 600. The UM program, processes and timeframes shall be in accordance with 42 C.F.R. 456, 42 C.F.R. 431, 42 C.F.R. 438. If the Contractor utilizes a private review agent, as defined in KRS 304.17A-600, the agent shall comply with all applicable requirements of KRS 304.17A-600 to 304.17A-633, as applicable. The Medical Director and Behavioral Health Director shall supervise the UM Program and shall be accessible and available for consultation as needed. The Contractor shall implement innovative and effective Utilization Management processes to ensure a high quality, clinically appropriate yet highly efficient and cost-effective cost -effective delivery system. The Contractor shall continually evaluate the cost and quality of medical services delivered by b y Providers. The Contractor shall apply objective and evidence-based criteria that take the individual Enrollee’s circumstances when determining the Medical Necessity of health care services. The Contractor shall have a written plan for the UM program that details the program structure and, if delegated, includes a clear definition of authority and accountability for all activities between the Contractor and entities to which the Contractor delegates UM activities. The UM Program and Review Plan shall comply with KRS 304.17A-600 and include the following information, at a minimum:
A. Scope X. Xxxxx of the program;
B. The processes and information sources used to determine service coverage;
C. List which services require PCP Referral; which services require Prior Authorization and how requests for initial and continuing services are processed;
D. Written policies and procedures to evaluate Medical Necessity, the criteria used, information sources, timeframes and the process used to review, approve, or deny the provision of services, as needed, including those specific to the EPSDT program;
E. Policies and procedures to evaluate discharge criteria, site of services, levels of care, triage decisions and cultural competence of care delivery;
F. Written policies and procedures for monitoring to ensure clinically appropriate overall continuity of care;
G. Written policies to ensure the coordination of services:
1. Between settings of care, including appropriate Discharge Planning for short-term and long-term hospital and institutional stays;
2. With the services the Enrollee receives from any other MCO;
3. With the services the Enrollee receives in FFS; and
4. With the services the Enrollee receives from community and social support providers.
H. Written policies and procedures that explain how Prior Authorization data shall be incorporated into the Contractor’s overall Quality Improvement Plan;
I. Education plan for UM Program staff in the application of related policies and use of designated criteria in making UM decisions;
J. Written policies and procedures for complying with the Mental Health Parity And Addiction Equity Act (MHPAEA);
Appears in 1 contract
Samples: Medicaid Managed Care Contract
