Common use of Utilization Review and Control Clause in Contracts

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. 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 and WVCHIP State PlanPlans, 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. 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 and WVCHIP State PlanPlans, 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 Early and Periodic Screening, Diagnosis, and Treatment (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. 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 or BSS State PlanPlans, 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 enrolleemember’s ongoing need for such services and supports; and 3. Family planning services are provided in a manner that protects and enables the enrolleemember’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 requirementsEarly and Periodic Screening, Diagnosis, and the Treatment (EPSDT) requirements and respective federal regulations. BMS The Department will have the authority to override any MCO utilization management guideline on a case- case-by-case basis. The BMS Department Medical Director shall or BSS 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. 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 or BCF State PlanPlans, 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 enrolleemember’s ongoing need for such services and supports; and 3. Family planning services are provided in a manner that protects and enables the enrolleemember’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, requirements and the respective federal regulations. BMS The Department will have the authority to override any MCO utilization management guideline on a case- case-by-case basis. The BMS DHHR Medical Director shall 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. 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 or BSS State PlanPlans, 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 enrolleemember’s ongoing need for such services and supports; and 3. Family planning services are provided in a manner that protects and enables the enrolleemember’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, requirements and the respective federal regulations. BMS The Department will have the authority to override any MCO utilization management guideline on a case- case-by-case basis. The BMS DHHR Medical Director shall or BSS 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.