Common use of Utilization Management (UM Clause in Contracts

Utilization Management (UM. a. The County must have documented policies and procedures for all UM activities that involve determining medical necessity, and the approval or denial of mental health services. Qualified mental health professionals must be involved in any decision- making that requires clinical judgment. The decision to deny, reduce or authorize a service that is less than requested must be made by a health professional with appropriate clinical expertise in treating the affected member’s condition(s). The County may not deny coverage, penalize providers, or give incentives or payments to providers or enrollees that are intended to reward inappropriate restrictions on care or result in the under-utilization of services. Criteria used to determine medical necessity and appropriateness must be communicated to providers. The criteria for determining medical necessity may not be more stringent than DHS 101.03 (96m), Wis. Adm. Code. b. If the County utilizes telephone triage, nurse lines or other demand management systems, the County must document review and approval of qualification criteria of staff and of clinical protocols or guidelines used in the system. The system’s performance will be evaluated annually in terms of clinical appropriateness. c. The prior authorization policies must specify time frames for responding to requests for initial and continued service determinations, specify information required for authorization decision, provide for consultation with the requesting provider when appropriate, and provide for expedited responses to requests for authorization of urgently needed services. In addition, the County must have in effect mechanisms to ensure consistent application of review criteria for authorization decisions (inter-rater reliability). Within the time frames specified, the County must give the member or their authorized representative and the requesting provider written notice of: 1) The decision to deny, limit, reduce, delay or terminate a service along with the reasons for the decision. 2) The member’s grievance and appeal rights, as detailed in the Member Grievances and Appeals Guide. 3) Denial of payment, at the time of any action affecting the claim. The notice(s) must adhere to the timing and content requirements detailed in the Member Grievances and Appeals Guide. Authorization decisions must be made within the following time frames and in all cases as expeditiously as the member’s condition requires: 1) Within 14 days of the receipt of the request, or; 2) Within three (3) working days if the physician indicates or the County determines that following the ordinary time frame could jeopardize the member’s health or ability to regain maximum function. One extension of up to 14 days may be allowed if the member requests it or if the County justifies the need for more information. On the date that the time frames expire, the County gives notice that service authorization decisions are not reached. Untimely service authorizations constitute a denial and are thus adverse actions. d. Criteria for decisions on coverage and medical necessity shall be clearly documented, based on reasonable medical evidence, current standards of mental health practice, or a consensus of relevant mental health care professionals, and regularly updated. e. The County oversees and is accountable for any functions and responsibilities that it delegates to any subcontractor.

Utilization Management (UM. a. The County must have documented policies and procedures for all UM activities that involve determining medical necessity, and the approval or denial of mental health services. Qualified mental health professionals must be involved in any decision- making that requires clinical judgment. The decision to deny, reduce or authorize a service that is less than requested must be made by a health professional with appropriate clinical expertise in treating the affected member’s condition(s). The County may not deny coverage, penalize providers, or give incentives or payments to providers or enrollees that are intended to reward inappropriate restrictions on care or result in the under-utilization of services. Criteria used to determine medical necessity and appropriateness must be communicated to providers. The criteria for determining medical necessity may not be more stringent than DHS HFS 101.03 (96m), Wis. Adm. Code. b. If the County utilizes telephone triage, nurse lines or other demand management systems, the County must document review and approval of qualification criteria of staff and of clinical protocols or guidelines used in the system. The system’s performance will be evaluated annually in terms of clinical appropriateness. c. The prior authorization policies must specify time frames for responding to requests for initial and continued service determinations, specify information required for authorization decision, provide for consultation with the requesting provider when appropriate, and provide for expedited responses to requests for authorization of urgently needed services. In addition, the County must have in effect mechanisms to ensure consistent application of review criteria for authorization decisions (inter-rater reliability). Within the time frames specified, the County must give the member or their authorized representative and the requesting provider written notice of: 1) The decision to deny, limit, reduce, delay or terminate a service along with the reasons for the decision. 2) The member’s grievance and appeal rights, as detailed in the Member Grievances and Appeals Guide. 3) Denial of payment, at the time of any action affecting the claim. The notice(s) must adhere to the timing and content requirements detailed in the Member Grievances and Appeals Guide. Authorization decisions must be made within the following time frames and in all cases as expeditiously as the member’s condition requires: 1) Within 14 days of the receipt of the request, or; 2) Within three (3) working days if the physician indicates or the County determines that following the ordinary time frame could jeopardize the member’s health or ability to regain maximum function. One extension of up to 14 days may be allowed if the member requests it or if the County justifies the need for more information. On the date that the time frames expire, the County gives notice that service authorization decisions are not reached. Untimely service authorizations constitute a denial and are thus adverse actions. d. Criteria for decisions on coverage and medical necessity shall be clearly documented, based on reasonable medical evidence, current standards of mental health practice, or a consensus of relevant mental health care professionals, and regularly updated. e. The County oversees and is accountable for any functions and responsibilities that it delegates to any subcontractor.