Utilization Review and Control. In accordance with 42 CFR §438.210(a)(4), the MCO may place appropriate limits on the covered services provided under this Contract on the basis of criteria applied under the Medicaid State Plan, such as medical necessity or for the purpose of utilization control, provided that:
1. MCO services can reasonably be expected to achieve the purpose for which such services are furnished;
2. Services supporting individuals with ongoing or chronic conditions are authorized in a manner that reflects the enrollee’s ongoing need for such services and supports; and
3. Family planning services are provided in a manner that protects and enables the enrollee’s freedom to choose the method of family planning to be used. The MCO must ensure that services are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished. The MCO is prohibited from arbitrarily denying or reducing the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition. Notwithstanding the above, all covered services must be provided in compliance with the Mental Health Parity and Addiction Equity Act of 2008, and with EPSDT requirements, and the respective federal regulations. BMS will have the authority to override any MCO utilization management guideline on a case- by-case basis. The BMS Medical Director shall coordinate with the MCO Medical Director in the event an override is appropriate based on thorough internal review. The MCO must be responsible for payment should a utilization management guideline be overridden.
Utilization Review and Control. The MCO may place appropriate limits on the covered services provided under this Contract on the basis of criteria applied under the State plan, such as medical necessity or for the purpose of utilization control, provided the MCO services can reasonably be expected to achieve the purpose for which such services are furnished. The MCO must ensure that services are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished. The MCO is prohibited from arbitrarily denying or reducing the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition. Notwithstanding the above, all covered services must be provided in compliance with the Mental Health Parity and Addiction Equity Act of 2008 and its respective federal regulations. The Department will have the authority to override any MCO utilization management guideline on a case-by-case basis. The BMS Medical Director shall coordinate with the MCO Medical Director in the event an override is appropriate based on thorough internal review. The MCO shall be responsible for payment should a utilization management guideline be overridden.
Utilization Review and Control. The MCO may place appropriate limits on the covered services provided under this Contract on the basis of criteria applied under the Medicaid or BCF State Plans, such as medical necessity or for the purpose of utilization control, provided the MCO services can reasonably be expected to achieve the purpose for which such services are furnished. The MCO must ensure that services are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished. The MCO is prohibited from arbitrarily denying or reducing the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition. Notwithstanding the above, all covered services must be provided in compliance with the Mental Health Parity and Addiction Equity Act of 2008, and with EPSDT requirements and respective federal regulations. The Department will have the authority to override any MCO utilization management guideline on a case-by-case basis. The DHHR Medical Director or BCF designee must coordinate with the MCO Medical Director in the event an override is appropriate based on thorough internal review. The MCO must be responsible for payment should a utilization management guideline be overridden.
Utilization Review and Control. Waive, to the extent allowed by law, any present Department requirements for prior authorization, second opinions, co-payment, or other Medicaid restrictions for the provision of contract services provided by the HMO to enrollees, except as may be provided in Addendum II.
Utilization Review and Control. The Department will waive any current Department fee-for-service requirements for prior authorization, second opinions, or other fee-for-service Medicaid restrictions for the provision of those contract services provided by the MCO to enrollees, except when such requirements are provided by State or Federal law or by the State Plan.
Utilization Review and Control. The DEPARTMENT shall waive, to the extent allowed by law, any current DEPARTMENT requirements for prior authorization, second opinions, copayment, or other Medicaid restrictions for the provision of contract services provided by the MCO to Members.
Utilization Review and Control. The MCO may place appropriate limits on the covered services provided under this Contract on the basis of criteria applied under the State plan, such as medical necessity or for the purpose of utilization control, provided the MCO services can reasonably be expected to achieve the purpose for which such services are furnished. The MCO must ensure that services are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished. The MCO is prohibited from arbitrarily denying or reducing the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition. The Department will have the authority to override any MCO utilization management guideline on a case-by-case basis. .
