Utilization Management Programs. In accordance with Sections 2.4 and 2.8 of the Three-Way, and OAC rules 5160-58-01.1 and 5160-26-03.1, the MCOP shall implement utilization management programs with clearly defined structures and processes to maximize the effectiveness of the care provided to dual benefits and Medicaid only members. Pursuant to the criteria in ORC Section 5160.34, the MCOP is prohibited from retroactively denying a prior authorization (PA) request as a utilization management strategy. When performing a pre-payment review of a claim the MCOP may not deny the claim due to medical necessity when the service was prior authorized. In addition, the MCOP shall permit the retrospective review of a claim submitted for a service where PA was required, but not obtained, pursuant to the criteria in ORC Section 5160.34. In accordance with ORC Section 5160.34, the MCOP is required to establish a streamlined provider appeal process relating to adverse PA determinations.
Appears in 12 contracts
Samples: The Ohio Department of Medicaid Mycare Ohio Provider Agreement for Mycare Ohio Plan, The Ohio Department of Medicaid Mycare Ohio Provider Agreement for Mycare Ohio Plan, The Ohio Department of Medicaid Mycare Ohio Provider Agreement for Mycare Ohio Plan
