Utilization Management Requirements. 11.1.1 The Contractor’s Behavioral Health Medical Director will provide guidance, leadership and oversight of the Contractor’s Utilization Management (UM) program for Contracted Services used by Consumers. The following activities may be carried out in conjunction with the administrative staff or other clinical staff, but are the responsibility of the Behavioral Health Medical Director to oversee: 11.1.1.1 Processes for evaluation and referral to services. 11.1.1.2 Review of consistent application of criteria for provision of services within Available Resources and related complaints and Grievances. 11.1.1.3 Review of assessment and treatment services against clinical practice standards. Clinical practice standards include, but are not limited to evidenced-based practice guidelines, culturally appropriate services, discharge planning guidelines, and community standards governing activities such as coordination of care among treating professionals. 11.1.1.4 Monitor for over-utilization and under-utilization of services, including Crisis Services. 11.1.1.5 Ensure that resource management and UM activities are not structured in such a way as to provide incentives for any individual or entity to deny, limit, or discontinue medically necessary behavioral health services inconsistent with the Contractors policy and procedure for determining eligibility for services within Available Resources. 11.1.2 The Contractor shall develop and implement UM protocols for all services and supports funded solely or in part through GFS or FBG funds. The UM protocols shall comply with the following provisions: 11.1.2.1 The Contractor must have policies and procedures that establish a standardized methodology for determining when GFS and FBG resources are available for the provision of behavioral health services. The methodology shall include the following components: 11.1.2.1.1 The review may be an aggregate review of spending across GFS and FBG fund sources under the Contract. 11.1.2.1.2 For any case-specific review decisions, the Contractor shall maintain Level of Care Guidelines for making authorization, continued stay and discharge determinations. The Level of Care Guidelines shall address GFS and SAPT priority population requirements. The Contractor shall use ASAM Level of Care Guidelines to make placement decisions for all SUD services. 11.1.2.1.3 A plan to address under- or over-utilization patterns with any provider to avoid unspent funds or gaps in service at the end of a contract period due to limits in Available Resources. 11.1.2.1.4 Education and technical assistance to address issues related to quality of care, medical necessity, timely and accurate claims submission or aligning service utilization with allocated funds to avoid disruption in service or unspent funds at the end of a contract year. 11.1.2.1.5 Corrective action with providers, as necessary, to address issues with compliance with state and federal Regulations or ongoing issues with patterns of service utilization. 11.1.2.1.6 A process to make payment denials and adjustments when patterns of utilization deviate from state, federal or Contract requirements (e.g., single source funding). 11.1.2.2 The Contractor shall monitor provider discharge planning to ensure providers meet requirements for discharge planning defined in this Contract. 11.1.3 The Contractor shall educate UM staff in the application of UM protocols, communicating the criteria used in making UM decisions. UM protocols shall recognize and respect the cultural needs of diverse populations. 11.1.4 The Contractor shall demonstrate that all UM staff making service authorization decisions have been trained and are competent in working with the specific area of service which they are authorizing and managing, including but not limited to, co- occurring mental health and SUDs, co-occurring behavioral health and medical diagnoses, and co-occurring behavioral health and I/DD. 11.1.5 The Contractor’s policies and procedures related to UM shall comply with, and require the compliance of Subcontractors with delegated authority for UM requirements described in this section. 11.1.6 The Contractor shall develop and maintain a Utilization Management Program (UMP) description and policies and procedures that include the following components: 11.1.6.1 Monthly and annual utilization reports. The following minimum measure set shall be included, with monthly and year to date performance for each metric. Monthly reports are due the 15th of the month following the month being reported. Annual reports are due July 30 of each year: 11.1.6.1.1 Number of unduplicated individuals served by fund source. 11.1.6.1.2 Service dollars expended as a percent of grant allocation by service type, by provider, and in aggregate by fund source. 11.1.6.1.3 Number of FBG providers at or above capacity by service type. 11.1.6.1.4 Number of providers identified as outliers by service type and by fund source. 11.1.6.1.5 Number of provider interventions by type of intervention (e.g., education, technical assistance, corrective action). 11.1.6.1.6 Other GFS and FBG reporting requirements as determined by HCA and DSHS. 11.1.7 For each RSA, the Contractor shall submit to HCA Progress Reports as specified in Exhibit G no later than August 1 each year. 11.1.8 Authorization reviews shall be conducted by state licensed Behavioral Health Professionals with experience working with the populations and/or settings under review. 11.1.8.1 The Contractor shall have UM staff with experience and expertise in working with TAY, adults, and older adults with a SUD and are receiving medication- assisted treatment. 11.1.9 Adverse utilization review determinations based on medical necessity including any decision to authorize a service in an amount, duration or scope that is less than requested shall be conducted by: 11.1.9.1 A physician board-certified or board-eligible in General Psychiatry or Child Psychiatry; 11.1.9.2 A physician board-certified or board-eligible in Addiction Medicine, a Subspecialty in Addiction Psychiatry; or 11.1.9.3 A licensed, doctoral level psychologist. 11.1.10 The Contractor shall ensure that any behavioral health clinical peer reviewer who is subcontracted or works in a service center other than the Contractor’s Washington State service center shall be subject to the same supervisory oversight and quality monitoring as staff located in the Washington State service center, to include participation in initial orientation and at least annual training on Washington State specific benefits, protocols and initiatives. 11.1.11 The Contractor shall ensure that any behavioral health actions must be peer-to-peer, that is, the credential of the licensed clinician making the decision to authorize service in an amount, duration or scope that is less than requested must be at least equal to that of the recommending clinician. In addition: 11.1.11.1 A physician board-certified or board-eligible in General Psychiatry must review all inpatient level of care actions for psychiatric treatment. 11.1.11.2 A physician board-certified or board-eligible in Addiction Medicine, or a subspecialty in Addiction Psychiatry, must review all inpatient level of care actions (denials) for SUD treatment. 11.1.12 The Contractor shall ensure that Appeals shall be evaluated by health care providers who were not involved in the initial decision and who have appropriate expertise in the field of medicine that encompasses the person’s condition or disease. 11.1.12.1 The Contractor shall ensure documentation of timelines for Appeals shall be in accordance with the Appeal Process provisions of the Grievance System Section of this Contract. 11.1.13 The Contractor shall not penalize or threaten a provider or facility with a reduction in future payment or termination of Participating Provider or participating facility status because the provider or facility disputes the Contractor’s determination with respect to coverage or payment for health care service.
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Utilization Management Requirements. 11.1.1 The Contractor’s Behavioral Health Medical Director will provide guidance, leadership and oversight of the Contractor’s Utilization Management (UM) program for Contracted Services used by Consumers. The following activities may be carried out in conjunction with the administrative staff or other clinical staff, but are the responsibility of the Behavioral Health Medical Director to oversee:
11.1.1.1 Processes for evaluation and referral to services.
11.1.1.2 Review of consistent application of criteria for provision of services within Available Resources and related complaints and Grievancesgrievances.
11.1.1.3 Review of assessment and treatment services against clinical practice standards. Clinical practice standards include, but are not limited to evidenced-based practice guidelines, culturally appropriate services, discharge planning guidelines, and community standards governing activities such as coordination of care among treating professionals.
11.1.1.4 Monitor Monitoring for over-utilization and under-utilization of services, including Crisis Services.
11.1.1.5 Ensure Ensuring that resource management and UM activities are not structured in such a way as to provide incentives for any individual or entity to deny, limit, or discontinue medically necessary behavioral health services inconsistent with the Contractors policy and procedure for determining eligibility for services within Available Resources.
11.1.2 The Contractor shall develop and implement UM protocols for all services and supports funded solely or in part through GFS or FBG funds. The UM protocols shall comply with the following provisions:
11.1.2.1 The Contractor must have policies and procedures that establish a standardized methodology for determining when GFS and FBG resources are available for the provision of behavioral health services. The methodology shall include the following components:
11.1.2.1.1 The review may be an aggregate review of spending across GFS and FBG SAPT fund sources under the Contract.
11.1.2.1.2 For any case-case specific review decisions, the Contractor shall maintain Level of Care Guidelines for making authorization, continued stay and discharge determinations. The Level of Care Guidelines shall address GFS and SAPT priority population requirements. The Contractor shall ensure use of ASAM Level of Care Guidelines to make placement decisions for all SUD services.
11.1.2.1.3 A plan to address under- or over-utilization patterns with any provider to avoid unspent funds or gaps in service at the end of a contract period due to limits in Available Resources.
11.1.2.1.4 Education and technical assistance to address issues related to quality of care, medical necessity, timely and accurate claims submission or aligning service utilization with allocated funds to avoid disruption in service or unspent funds at the end of a contract year.
11.1.2.1.5 Corrective action with providers, as necessary, to address issues with compliance with state and federal Regulations or ongoing issues with patterns of service utilization.
11.1.2.1.6 A process to make payment denials and adjustments when patterns of utilization deviate from state, federal or Contract requirements (e.g., single source funding).
11.1.2.2 The Contractor shall monitor provider discharge planning to ensure providers meet contractual requirements for discharge planning defined in this Contract.
11.1.3 The Contractor shall educate UM staff in the application of UM protocols, communicating the criteria used in making UM decisions. UM protocols shall recognize and respect the cultural needs of diverse populations.
11.1.4 The Contractor shall demonstrate that all UM staff making service authorization decisions have been trained and are competent in working with the specific area of service which they are authorizing and managingmanaging including, including but not limited to, co- co-occurring mental health and SUDs, co-occurring behavioral health and medical diagnoses, and co-occurring behavioral health and I/DD.
11.1.5 The Contractor’s policies and procedures related to UM shall comply with, and require the compliance of Subcontractors with delegated authority for UM requirements described in this section.
11.1.6 The Contractor shall develop and maintain a Utilization Management Program (UMP) description and policies and procedures that include the following components:
11.1.6.1 Monthly and annual utilization reports. The following minimum measure set shall be included, with monthly and year to date performance for each metric. Monthly reports are due the 15th of the month following the month being reported. Annual reports are due July 30 April 30th of each year:
11.1.6.1.1 11.1.6.2 Number of unduplicated individuals served by fund sourcesource (i.e., GFS SAPT block grant).
11.1.6.1.2 11.1.6.3 Service dollars expended as a percent of grant allocation by service type, by provider, and in aggregate by fund source.
11.1.6.1.3 11.1.6.4 Number of FBG providers at or above capacity by service type.
11.1.6.1.4 11.1.6.5 Number of providers identified as outliers by service type and by fund source.
11.1.6.1.5 11.1.6.6 Number of provider interventions by type of intervention (e.g., education, technical assistance, corrective action).
11.1.6.1.6 11.1.6.7 Other GFS and FBG reporting requirements as determined by HCA and DSHS.
11.1.7 For each RSA, the The Contractor shall must submit to HCA the Federal Block Grant Progress Reports Report as specified in Exhibit G no later than August 1 within thirty (30) days after the end of each state fiscal year. This report shall be submitted annually beginning in calendar year 2018.
11.1.8 Authorization reviews shall be conducted by state licensed Behavioral Health Professionals with experience working with the populations and/or settings under review.
11.1.8.1 The Contractor shall have UM staff with experience and expertise in working with TAY, adults, and older adults with a SUD and are receiving medication- assisted treatment.
11.1.9 Adverse utilization review determinations based on medical necessity including any decision to authorize a service in an amount, duration or scope that is less than requested shall be conducted by:
11.1.9.1 A physician board-certified or board-eligible in General Psychiatry or Child Psychiatry;
11.1.9.2 A physician board-certified or board-eligible in Addiction Medicine, a Subspecialty in Addiction Psychiatry; or
11.1.9.3 A licensed, doctoral level psychologist.
11.1.10 The Contractor shall ensure that any behavioral health clinical peer reviewer who is subcontracted or works in a service center other than the Contractor’s Washington State service center shall be subject to the same supervisory oversight and quality monitoring as staff located in the Washington State service center, to include participation in initial orientation and at least annual training on Washington State specific benefits, protocols and initiatives.
11.1.11 The Contractor shall ensure that any behavioral health actions must be peer-to-peer, that is, the credential of the licensed clinician making the decision to authorize service in an amount, duration or scope that is less than requested must be at least equal to that of the recommending clinician. In addition:
11.1.11.1 A physician board-certified or board-eligible in General Psychiatry must review all inpatient level of care actions for psychiatric treatment.
11.1.11.2 A physician board-certified or board-eligible in Addiction Medicine, or a subspecialty in Addiction Psychiatry, ; must review all inpatient level of care actions (denials) for SUD treatment.
11.1.12 The Contractor shall ensure that Appeals of adverse determinations shall be evaluated by health care providers who were not involved in the initial decision and who have appropriate expertise in the field of medicine that encompasses the person’s condition or disease.
11.1.12.1 The Contractor shall ensure documentation of timelines for Appeals shall be in accordance with the Appeal Process provisions of the Grievance System Section of this Contract.
11.1.13 The Contractor shall not penalize or threaten a provider or facility with a reduction in future payment or termination of Participating Provider or participating facility status because the provider or facility disputes the Contractor’s determination with respect to coverage or payment for health care service.
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Sources: Behavioral Health Administrative Services Organization Contract