Utilization Management Plan. DVHA must have in effect mechanisms to detect both underutilization and overutilization of services and to assess the quality and appropriateness of care furnished to enrollees with special health care needs. DVHA has delegated the function of assessing the quality and appropriateness of care furnished to beneficiaries with special health care needs to the Department of Disabilities, Aging and Independent Living (DAIL) and the Department of Mental Health (DMH). DVHA and its IGA partners, when applicable, shall adopt practice guidelines that are based on valid clinical evidence, or based on the consensus of health care professionals, consideration of the needs of the enrollees, and consultation with health care professionals who participate in the Global Commitment to Health Demonstration and other program stakeholders. Program guidelines shall be reviewed and updated periodically as appropriate. DVHA shall disseminate guidelines in collaboration with its IGA partners and shall require the Departments to disseminate the guidelines among all of their designated providers. These practice guidelines will also be made available to enrollees upon request. Decisions for utilization management, enrollee education, coverage of services and other areas to which the guidelines apply shall be consistent with the guidelines. DVHA shall not structure compensation for any entity that conducts utilization management services in such a way as to provide incentives for the denial, limitation or discontinuation of medically necessary services to any enrollee.
Appears in 4 contracts
Sources: Intergovernmental Agreement, Intergovernmental Agreement, Intergovernmental Agreement