Underutilization of services Clause Samples
Underutilization of services. MCPs must monitor for the potential underutilization of services by their members in order to assure that all Medicaid-covered services are being provided, as required. If any underutilized services are identified, the MCP must immediately investigate and, if indicated, correct the problem(s) which resulted in such underutilization of services. The MCP’s monitoring efforts must, at a minimum, include the following activities: a) an annual review of their prior authorization procedures to determine that they do not unreasonably limit a member’s access to Medicaid-covered services; b) an annual review of the procedures providers are to follow in appealing the MCP’s denial of a prior authorization request to determine that the process does not unreasonably limit a member’s access to Medicaid-covered services; and c) ongoing monitoring of MCP service denials and utilization in order to identify services which may be underutilized.
Underutilization of services. In order to ensure all Medicaid-covered services are provided, as required, monitoring of the following areas shall occur:
1. The MCOPs shall annually review their prior authorization (PA) procedures to determine if they unreasonably limit a member’s access to Medicaid-covered services;
2. The MCOP shall annually review their appeals process for providers following the MCOP’s denial of a prior authorization request for a determination as to whether the appeals process unreasonably limits a member’s access to Medicaid-covered services;
3. The MCOP shall monitor, on an ongoing basis, service denials, and utilization in order to identify member services which may be underutilized; and
4. If any underutilized services or limits to a member’s access to Medicaid-covered services are identified, the MCOP shall immediately investigate and, if indicated, correct the problem(s).
Underutilization of services. MCPs must monitor for the potential underutilization of services by their members in order to assure that all Medicaid-covered services are being provided, as required. If any underutilized services are identified, the MCP must immediately investigate and, if indicated, correct the problem(s) which resulted in such underutilization of services. The MCP’s monitoring efforts must, at a minimum, include the following activities: For SFY 2004, the MCP must review their prior authorization procedures to determine that they do not unreasonably limit a member’s access to Medicaid-covered services. The MCP must also review the procedures providers are to follow in appealing the MCP’s denial of a prior authorization request to determine that the process does not unreasonably limit a member’s access to Medicaid-covered services. Beginning July 1, 2004, in addition to the MCP’s annual review of prior authorization procedures and their provider appeal procedures, the MCP must also monitor service denials and utilization on an ongoing basis in order to identify services which may be underutilized. Appendix I
Underutilization of services. In order to ensure that all Medicaid- covered services are provided, as required, monitoring of the following areas must occur: