Utilization Management (UM. Director who is an Ohio-licensed registered nurse or a physician with a current unencumbered license through the Ohio State Medical Board preferably with a certification as a Certified Professional in Health Care Quality (CPHQ) by the National Association for Health Care Quality (NAHQ) and/or Certified in Health Care Quality and Management (CHCQM) by the American Board of Quality Assurance and Utilization Review Providers. The UM Director is responsible for overseeing the day-to-day operational activities of the Utilization Management Program in accordance with state guidelines. The UM Director shall have experience in the activities of utilization management as specified in 42 CFR 438.210. Primary functions of the Director of Utilization Management position are to ensure:
i. There are written policies and procedures regarding authorization of services and that these are followed;
ii. Consistent application of review criteria for authorization decisions;
iii. Decisions to deny or reduce the amount of services are made by a health care professional who has appropriate clinical expertise in treating the enrollee's condition or disease;
iv. Notices of adverse action meet the requirements of 42 CFR 438.404; and
v. All decisions are made within the specified allowable time frames.
Utilization Management (UM a. The County must have documented policies and procedures for all UM activities that involve determining medical necessity, and the approval or denial of mental health services. Qualified mental health professionals must be involved in any decision- making that requires clinical judgment. The decision to deny, reduce or authorize a service that is less than requested must be made by a health professional with appropriate clinical expertise in treating the affected member’s condition(s). The County may not deny coverage, penalize providers, or give incentives or payments to providers or enrollees that are intended to reward inappropriate restrictions on care or result in the under-utilization of services. Criteria used to determine medical necessity and appropriateness must be communicated to providers. The criteria for determining medical necessity may not be more stringent than DHS 101.03 (96m), Wis. Adm. Code.
b. If the County utilizes telephone triage, nurse lines or other demand management systems, the County must document review and approval of qualification criteria of staff and of clinical protocols or guidelines used in the system. The system’s performance will be evaluated annually in terms of clinical appropriateness.
c. The prior authorization policies must specify time frames for responding to requests for initial and continued service determinations, specify information required for authorization decision, provide for consultation with the requesting provider when appropriate, and provide for expedited responses to requests for authorization of urgently needed services. In addition, the County must have in effect mechanisms to ensure consistent application of review criteria for authorization decisions (inter-rater reliability). Within the time frames specified, the County must give the member or their authorized representative and the requesting provider written notice of:
1) The decision to deny, limit, reduce, delay or terminate a service along with the reasons for the decision.
2) The member’s grievance and appeal rights, as detailed in the Member Grievances and Appeals Guide.
3) Denial of payment, at the time of any action affecting the claim. The notice(s) must adhere to the timing and content requirements detailed in the Member Grievances and Appeals Guide. Authorization decisions must be made within the following time frames and in all cases as expeditiously as the member’s condition requires:
1) Within 14 days of the receipt of the r...
Utilization Management (UM. Program
1. The Contractor shall have a Utilization Management (UM) Program assuring that beneficiaries have appropriate access to SUD services; medical necessity has been established, the beneficiary is at the appropriate ASAM level of care, and that the interventions are
Utilization Management (UM. A strategy designed to ensure that health care expenditures are restricted to those that are needed and appropriate by reviewing CDCR/CCHCS patient and/or DJJ youth medical records through the application of defined criteria and/or expert opinion. It assesses the efficiency of the health care process and the appropriateness of decision making related to the site of care, its frequency and its duration, through prospective, concurrent, and retrospective utilization reviews.
Utilization Management (UM. 1. The HMO must have documented policies and procedures for all UM activities that involve determining medical necessity, and the approval or denial of medical services. Qualified medical professionals must be involved in any decision-making that requires clinical judgment. The decision to deny, reduce or authorize a service that is less than requested must be made by a health professional with appropriate clinical expertise in treating the affected enrollee’s condition(s). Criteria used to determine medical necessity and appropriateness must be communicated to providers. The criteria for determining medical necessity may not be more stringent than HFS 101.03 (96m) Wis. Adm. Code.
2. If the HMO delegates any part of the UM program to a third party, the delegation must meet the requirements in Article II Delegations of Authority.
3. If the HMO utilizes telephone triage, nurse lines or other demand management systems, the HMO must document review and approval of qualification criteria of staff and of clinical protocols or guidelines used in the system. The system’s performance will be evaluated annually in terms of clinical appropriateness.
4. The HMO’s policies must specify time frames for responding to requests for initial and continued service determinations, specify information required for authorization decisions, provide for consultation with the requesting provider when appropriate, and provide for expedited responses to requests for authorization of urgently needed services. In addition, the HMO must have in effect mechanisms to ensure consistent application of review criteria for authorization decisions (interrater reliability).
a. Within the time frames specified, the HMO must give the enrollee and the requesting provider written notice of:
1) The decision to deny, limit, reduce, delay or terminate a service along with the reasons for the decision.
2) The enrollee’s right to file a grievance or request a state fair hearing.
b. Authorization decisions must be made within the following time frames and in all cases as expeditiously as the enrollee’s condition requires:
1) Within 14 calendar days of the receipt of the request, or
2) Within three business days if the physician indicates or the HMO determines that following the ordinary time frame could jeopardize the enrollee’s health or ability to regain maximum function. One extension of up to 14 calendar days may be allowed if the enrollee requests it or if the HMO justifies the need for more informa...
Utilization Management (UM. The CONTRACTOR shall:
(1) Comply with NMAC 8.305.8.13 regarding Standards for Utilization Management. The CONTRACTOR shall manage the use of limited resources, maximize the effectiveness of care by evaluating clinical appropriateness, and authorize the type and volume of services through fair, consistent and culturally competent decision making processes while ensuring equitable access to care and a successful link between care and outcomes. The Member’s ISP priorities and prolonged service authorizations applicable for individuals with chronic conditions shall be considered in the decision-making process.
(2) Define and submit annually to the State a written copy of the UM program description, UM plan, and UM evaluation, which shall include but is not limited to:
(a) a description of the program structure and accountability mechanisms;
(b) specific indicators that will be used for periodic performance tracking and trending as well as processes or mechanisms used for assessment and intervention; and
(c) an evaluation of the overall effectiveness of the UM plan, an overview of the UM activities and the impact of the UM plan on the quality of management and administrative activities. The review and analysis shall be incorporated in the development of the following year’s UM plan.
(3) Shall submit for review and approval to the State upon request all UR clinical and social service criteria to be utilized for prior authorization decision.
(4) Submit copies of updated or changed criteria to the State within two (2) business days upon request.
(5) Develop and implement written policies and procedures for review of utilization decisions to ensure their basis in sound clinical evidence and that they conform to Medical Necessity criteria.
(6) Develop written policies and procedures to issue extended prior authorization any Covered Service or goods expected to be required on an on-going basis to exceed six (6) months. These services shall be authorized for an extended period of time and the CONTRACTOR will provide for a review and periodic update of the course of treatment, as indicated.
(7) Ensure the involvement of appropriate, practicing practitioners in the development of UM procedures.
(8) Comply with the State’s standards, and applicable provisions of the Balanced Budget Act, related to timeliness of decisions including routine/non-routine urgent and emergent situations.
(9) Approve or deny Covered Services for routine/non-urgent and urgent care requests withi...
Utilization Management (UM. The process of evaluating necessity, appropriateness and efficiency of healthcare services through the revision of information about hospital, service or procedure from patients and/or providers to determine whether it meets established guidelines and criteria approved by the ADMINISTRATION, the HCO and TPA as applicable.
Utilization Management (UM. The process of evaluating the necessity, appropriateness and efficiency of health care services against established guidelines and criteria.
Utilization Management (UM. As subject to and further defined by the County/DHCS LIHP Contract, including without limitation Attachment 5 of Exhibit A and as further specified in Attachment A, Section IV(2) below:
a) Alliance will conduct UM for LIHP Covered Services pursuant to the Alliance’s policies and procedures and in accordance with the LIHP Program, with the exception of mental health benefits which will be the sole responsibility of the County and shall be conducted by the County pursuant to its own policies and procedures.
b) Alliance UM services will include i) setting up UM Criteria using the LIHP defined benefit package
Utilization Management (UM. Provider shall comply with Partners’ UM programs, quality management programs, and provider sanctions programs, provided that such programs shall not override the professional or ethical responsibility of Provider or interfere with Provider's ability to provide information or assistance to Provider’s patients. (Attachment F.a.xvii.p.319)
