Utilization Management Programs. The MCP shall implement clearly defined structures and processes to maximize the effectiveness of the care provided to members pursuant to OAC rule 5160-26-03. a. The MCP will participate in clinical and policy collaborative workgroups as specified by ODM to identify methods for improvement in the standardization of prior authorization processes and standards for services determined by ODM. The MCP will ensure appropriate subject matter experts are included and adhere to timelines established by ODM. b. The MCP will participate in a clinical and policy collaborative workgroup to identify methods for improvement in the prior authorization processes and clinical standards for applied behavioral analysis (ABA) services. The MCP will ensure appropriate subject matter experts are included and adhere to timelines established by ODM. c. Pursuant to the criteria in ORC section 5160.34(C), the MCP 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 MCP may not deny the claim due to medical necessity when the service was prior authorized. In addition, the MCP 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(B)(9). Also, ORC section 5160.34 requires the MCPs establish a streamlined provider appeal process relating to adverse PA determinations.
Appears in 10 contracts
Samples: Provider Agreement, Provider Agreement, Provider Agreement
