Common use of Utilization Management Activities Clause in Contracts

Utilization Management Activities. If the Contractor provides compensation to individuals or entities to conduct utilization management activities, compensation for these activities must not be structured so as to provide incentives for the individual or entity to deny, limit or discontinue medically necessary services to any Enrollee. Primary, Acute, and Preventive Care PCP Clinical Responsibilities The PCP must: Provide overall clinical direction and serve as a central point for the integration and coordination of the Covered Services listed in Appendix A. For individuals with Complex Care Needs, a PCT must be created and the PCP must participate as needed (see Section 2.4.B.2; and Assume clinical responsibility for each Enrollee upon the effective date of enrollment including, but not limited to: Making an initial clinical determination of Emergency Conditions, Urgent Care, or routine Enrollee status; Providing for the transition of existing services, equipment, and other resources to ensure safe, efficient continuity of care at enrollment; Providing primary medical services, including acute and preventive care; and Referring the Enrollee to specialty, long term care, and behavioral health Providers, as medically appropriate. Care Management Responsibilities of the PCP or his or her designee on the PCT. As the manager of care, the PCP or the PCP’s designee must: With the Enrollee and the Enrollee’s designated representative, if any, develop an IPC; In the presence of Complex Care Needs, implement a comprehensive evaluation process to be performed by a PCT, which will include an in-home or in-facility component. Enrollees with Complex Care Needs will have their care managed by a PCT; On an ongoing basis, consult with and advise acute, specialty, long term care, and behavioral health Providers about care plans and clinically appropriate interventions; Conduct Ongoing Assessments appropriately and, as required in this Contract, adjust Individualized Plans of Care as necessary and with enrollee’s knowledge, and communicate the information to the Enrollee’s Providers in timely manner; With the assistance of the GSSC, if any, promote independent functioning of the Enrollee and provide services in the most appropriate, least restrictive environment; Document and comply with advance directives about the Enrollee's wishes for future treatment and health care decisions; Assist in the designation of a health care proxy, if the Enrollee wants one; Maintain the CER, including but not limited to appropriate and timely entries about the care provided, diagnoses determined, medications prescribed, and treatment plans developed and designate the physical location of the record for each Enrollee (see Section 2.4.A.8-10; and Communicate with the Enrollee, and the Enrollee’s family members and significant caregivers, if any and as appropriate under HIPAA, about the Enrollee's medical, social, and psychological needs. In delivering the Covered Services referenced in Appendix A that relate to long term care services, the Contractor must demonstrate the capacity to provide coordination of care and expert care management through the PCT. The Contractor must ensure that: The PCT arranges, delivers, and monitors long term care services on an ongoing basis; and The measurement of the Functional Status of Enrollees is performed at Initial and Ongoing Assessments. Reports will be produced in accordance with Section 2.13.E. Continuum of Long Term Care The Contractor must arrange and pay for: Community alternatives to institutional care (see Appendix A); Other transitional, respite, and residential support services to maintain Enrollees safely in the community, based on assessment by the Contractor of Functional need and cost effectiveness of the services being requested; Nursing facility services for Enrollees who meet applicable screening requirements (in accordance with 130 CMR Chapter 456 and Chapters 515 through 524) and for whom the Contractor has no community service package appropriate and available to meet the Enrollee’s medical needs; and Other institutional services as determined by the PCT. Pre-Admission Screening and Resident Review (PASRR) Evaluation The Contractor must comply with federal regulations requiring referral of nursing facility eligible Enrollees, as appropriate, for PASRR evaluation for mental illness and developmental disability treatment pursuant to the Omnibus Budget Reconciliation Act of 1987, as amended, and 42 CFR 483.100 through 483.138. Behavioral Health Systematic Early Identification and Intervention for Behavioral Health Services Behavioral health conditions must be systematically identified and addressed by the Enrollee's PCP or PCT at the Initial and Ongoing Assessments through the use of appropriate mental-health screening tools as designated or approved by EOHHS. When appropriate, the Contractor must ensure that referrals for specialty behavioral health services are made promptly, monitored, and documented in the CER. Services for Enrollees with Serious and Persistent Mental Illness The Contractor must ensure that Enrollees with serious and persistent mental illness have access to ongoing medication review and monitoring, day treatment, and other milieu alternatives to conventional therapy. The PCT must coordinate services with additional support services the member may be receiving, including but not limited to services provided by or through state agencies such as DMH or DDS, as appropriate. For such Enrollees, a qualified behavioral health clinician (see Section 2.5.B) must be part of the PCT. As necessary, care coordination with the Department of Mental Health must be provided. Continuum of Behavioral Health Care The Contractor must offer a continuum of behavioral health care that is coordinated with PCPs or PCTs, as appropriate, and includes but is not limited to: A range of services from acute inpatient treatment to intermittent professional and supportive care for delivering behavioral health services to Enrollees residing in the community or in nursing facilities; and Diversionary services that offer safe community alternatives to inpatient hospital services. (See Appendix A.) Behavioral Health Responsibilities The Contractor must manage the provision of all behavioral health services. When services for Emergency Conditions are needed, the Enrollee may seek care from any qualified behavioral health Provider. The care-management protocol for Enrollees must encourage appropriate access to behavioral health care in all settings. For Enrollees who require behavioral health services, the behavioral health Provider must: With the Enrollee and the Enrollee’s designated representative, if any, develop the behavioral health portion of the IPC for each Enrollee in accordance with accepted clinical practice. The IPC must be signed or otherwise approved by the Enrollee or the Enrollee’s designated representative, if any; With the input of the PCP or PCT, as appropriate, determine clinically appropriate interventions on an on-going basis, with the goal of promoting the independent functioning of the Enrollee; Make appropriate and timely entries into the CER about the behavioral health assessment, diagnosis determined, medications prescribed, if any, and Individualized Plan of Care developed. As stated in Section 2.4.A.10.d, psychotherapeutic session notes must not be recorded in the CER; and Obtain authorization from the PCP or PCT, as appropriate, for any non-emergency services, except when authorization is specifically not required under this Contract. Coordination of Medication