Common use of Utilization Management Programs Clause in Contracts

Utilization Management Programs. In accordance with Sections 2.4 and 2.8 of the Three-Way, and OAC rules 5160-58-01.1 and 5160-26-03.1, the MCOP shall implement utilization management programs with clearly defined structures and processes to maximize the effectiveness of the care provided to dual benefits and Medicaid only members. Pursuant to the criteria in ORC Section 5160.34, the MCOP is prohibited from retroactively denying a prior authorization (PA) request as a utilization management strategy. In addition, the MCOP shall permit the retrospective review of a claim submitted for a service where PA was required, but not obtained, pursuant to the criteria in ORC Section 5160.34. In accordance with ORC Section 5160.34, the MCOP is required to establish a streamlined provider appeal process relating to adverse PA determinations. a. The MCOP will participate in clinical and policy collaborative workgroups as specified by ODM to identify methods for improvement in the standardization of prior authorization processes and standards for services determined by ODM. The MCOP will ensure appropriate subject matter experts are included and adhere to timelines established by ODM.