Utilization Management Requirements. Failure to meet the requirements of the Utilization Management Program may result in a reduction or denial of benefits even if the services are Medically Necessary. Prior authorization from CareFirst will be obtained by In-Network Providers located in the CareFirst service area. It is the Member's responsibility to obtain prior authorization when services are rendered outside of the CareFirst service area and for services rendered by Out-of-Network Non-Preferred Providers.
Utilization Management Requirements. 11.1.1 The Contractor’s Behavioral Health Medical Director will provide guidance, leadership and oversight of the Contractor’s Utilization Management (UM) program for Contracted Services used by Consumers. The following activities may be carried out in conjunction with the administrative staff or other clinical staff, but are the responsibility of the Behavioral Health Medical Director to oversee:
11.1.1.1 Processes for evaluation and referral to services.
11.1.1.2 Review of consistent application of criteria for provision of services within Available Resources and related complaints and Grievances.
11.1.1.3 Review of assessment and treatment services against clinical practice standards. Clinical practice standards include, but are not limited to evidenced-based practice guidelines, culturally appropriate services, discharge planning guidelines, and community standards governing activities such as coordination of care among treating professionals.
11.1.1.4 Monitor for over-utilization and under-utilization of services, including Crisis Services.
11.1.1.5 Ensure that resource management and UM activities are not structured in such a way as to provide incentives for any individual or entity to deny, limit, or discontinue medically necessary behavioral health services inconsistent with the Contractors policy and procedure for determining eligibility for services within Available Resources.
11.1.2 The Contractor shall develop and implement UM protocols for all services and supports funded solely or in part through GFS or FBG funds. The UM protocols shall comply with the following provisions:
11.1.2.1 The Contractor must have policies and procedures that establish a standardized methodology for determining when GFS and FBG resources are available for the provision of behavioral health services. The methodology shall include the following components:
11.1.2.1.1 The review may be an aggregate review of spending across GFS and FBG fund sources under the Contract.
11.1.2.1.2 For any case-specific review decisions, the Contractor shall maintain Level of Care Guidelines for making authorization, continued stay and discharge determinations. The Level of Care Guidelines shall address GFS and SAPT priority population requirements. The Contractor shall use ASAM Level of Care Guidelines to make placement decisions for all SUD services.
11.1.2.1.3 A plan to address under- or over-utilization patterns with any provider to avoid unspent funds or gaps in service at the end of...
Utilization Management Requirements. Provider shall abide by clinically sound criteria. Provider shall seek authorization prior to service delivery and provide accurate and thorough information requested so that service provision is not unduly delayed or disrupted.
Utilization Management Requirements. Provider shall participate in and comply with the LME’s Utilization Management process, which may include requirements for pre-authorization, concurrent review and care management, credentialing review, and a retrospective utilization review of services provided for Enrollees whose services are reimbursed by the LME. Provider shall provide LME with all necessary clinical information for the LME’s utilization management process. Provider shall provide specifically denominated clinical or encounter information required by the LME to meet applicable monitoring requirements within 15 calendar days of the request, except that LME may grant additional time to respond for good cause shown and depending upon the size and scope of the request. Additionally, Provider will provide any documentation directly to the LME for review when requested. Provider may satisfy any request for information by either paper or electronic/digital copy.
Utilization Management Requirements. 1.2.9.1 Contractor shall accept the IM+CANS established by the CCSO and the Enrollee’s CFT, as applicable, as the IPoC for Enrollees who are N.B. class members.
1.2.9.2 Contractor shall establish Utilization Management and Prior Authorization policies and procedures, subject to Prior Approval, for N.B. class members thatensures the following:
1.2.9.2.1 Utilization Management staff shall base any service utilization reviews conducted on community-based Behavioral Health servicesfor N.B. class members on the Enrollee’s completed IM+CANS.
1.2.9.2.2 Any service authorization activity for an N.B. Class Member takes into consideration the service recommendations of the Enrollee’s CFT, as applicable, and as documented on the Enrollee’s IM+CANS or other related CFT documentation.
1.2.9.2.3 Medical necessity and service utilization standards for community-based Behavioral Health services and Pathways services are consistent with Department established standards.
1.2.9.3 Contractor shall not prior authorize Pathways Services in a manner more restrictive than the Department’s fee-for-service system or apply any prior authorization or utilization management policies or procedures to Pathways or community-based Behavioral Health services for N.B. class members beyond those established and specifically approvedby the Department.
1.2.9.4 Contractor shall ensure that Utilization Management staff responsible for performing service utilization reviews for N.B. class members are adequately trained in the N.B consent decree and implementation planrequirements, IM+CANS, the Wraparoundprocess including therole of the child and family team, and as appropriate other relevant tools and clinical assessments (e.g. functional behavioral assessments, behavioral healthscreening tools).
Utilization Management Requirements. Provider agrees to ------------------------------------ participate in, cooperate with and comply with all decisions rendered in connection with Foundation's, an Affiliate's or a Payor's Utilization Management Program. The hospital shall submit indicator data relevant to its services to the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) Indicator Measurement System. The data will be submitted on a timely basis and meet the reasonable standards set by JCAHO for completeness and reliability. Provider also agrees to provide such other records and information as may be required or requested under such Utilization Management Program. Provider shall notify Foundation's Health Care Services Department in the event of any inpatient admission, in addition to any notification required by the Beneficiary's Capitated Medical Group/IPA.
Utilization Management Requirements. 11.1.1 The Contractor’s Behavioral Health Medical Director will provide guidance, leadership and oversight of the Contractor’s Utilization Management (UM) program for Contracted Services used by Individuals. The following activities may be carried out in conjunction with the administrative staff or other clinical staff, but are the responsibility of the Behavioral Health Medical Director to oversee:
11.1.1.1 Processes for evaluation and referral to services.
11.1.1.2 Review of consistent application of criteria for provision of services within Available Resources and review of related Grievances.
11.1.1.3 Review of assessment and treatment services against clinical practice standards. Clinical practice standards include, but are not limited to evidenced-based practice guidelines, culturally appropriate services, discharge planning guidelines, and activities such as coordination of care.
11.1.1.4 Monitor for over-utilization and under-utilization of services, including Crisis Services.
11.1.1.5 Ensure that resource management and UM activities are not structured in such a way as to provide incentives for any individual or entity to deny, limit, or discontinue medically necessary behavioral health services.
11.1.2 The Contractor shall develop and implement UM protocols for all services and supports funded solely or in part through GFS or FBG funds. The UM protocols shall comply with the following provisions:
11.1.2.1 The Contractor must have policies and procedures that establish a standardized methodology for determining when GFS and FBG resources are available for the provision of behavioral health services. The processes and methodology shall include the following components:
11.1.2.1.1 An aggregate of spending across GFS and FBG fund sources under the Contract.
11.1.2.1.2 For any case-specific review decisions, the Contractor shall maintain Level of Care Guidelines for making authorization, continued stay and discharge determinations. The Level of Care Guidelines shall address GFS and SABG priority population requirements. The Contractor shall use ASAM Criteria to make placement decisions for all SUD services.
11.1.2.1.3 A plan to address under- or over-utilization patterns with providers to avoid unspent funds or gaps in service at the end of a contract period due to limits in Available Resources.
11.1.2.1.4 Education and technical assistance to address issues related to quality of care, medical necessity, timely and accurate claims submission or aligni...
Utilization Management Requirements. RPO agrees and shall use commercially reasonable efforts to cause all RPO Providers to participate in, cooperate with and comply with all decisions rendered in connection with Texas HealthSpring's, an Affiliate's, or a Payor's Utilization Management Program. RPO also agrees and shall use commercially reasonable efforts to cause all RPO Providers to provide such records and other information as may be required or requested under such Utilization Management Program. RPO shall accept delegation of and perform utilization management with respect to Contracted Services provided under this Agreement in accordance with the Delegated Services Agreement. RPO shall perform such utilization management in accordance with the performance standards and criteria of Texas HealthSpring or a Payor. Texas HealthSpring shall have the right to audit RPO's performance of utilization management as solely determined by Texas HealthSpring and to reassume the obligation for utilization management in the event Texas HealthSpring determines that RPO either does not have the capacity to perform, or is not effectively performing utilization management.
Utilization Management Requirements. Whether announced or unannounced, Provider agrees to cooperate with, participate in, and abide by internal or external quality assessment reviews, Member Appeal Procedures, Utilization Management Program procedures, and Quality Management Program procedures established by the Plan, and to follow practice guidelines as described in the Provider Manual and other Plan notices.
Utilization Management Requirements. Certain Covered Services are subject to review and approval under Utilization Management requirements established by the Plan. Section 1.16 and Section 1.17 of this Agreement further describe Evergreen’s Utilization Management program and Covered Services subject to prior authorization.
