Common use of Utilization Review and Control Clause in Contracts

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 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 plansPlans, 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 shall must coordinate with the MCO Medical Director in the event an override is appropriate based on thorough internal review. The MCO shall must be responsible for payment should a utilization management guideline be overridden.