Common use of Utilization Management (UM Clause in Contracts

Utilization Management (UM. 1. The HMO must have documented policies and procedures for all UM activities that involve determining medical necessity, and the approval or denial of medical services. Qualified medical 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 enrollee’s condition(s). 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 HFS 101.03 (96m) Wis. Adm. Code. 2. If the HMO delegates any part of the UM program to a third party, the delegation must meet the requirements in Article II Delegations of Authority. 3. If the HMO utilizes telephone triage, nurse lines or other demand management systems, the HMO 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. 4. The HMO’s policies must specify time frames for responding to requests for initial and continued service determinations, specify information required for authorization decisions, 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 HMO must have in effect mechanisms to ensure consistent application of review criteria for authorization decisions (interrater reliability). a. Within the time frames specified, the HMO must give the enrollee 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 enrollee’s right to file a grievance or request a state fair hearing. HMO Contract for February 1, 2006 - December 31, 2007 b. Authorization decisions must be made within the following time frames and in all cases as expeditiously as the enrollee’s condition requires: 1) Within 14 calendar days of the receipt of the request, or 2) Within three business days if the physician indicates or the HMO determines that following the ordinary time frame could jeopardize the enrollee’s health or ability to regain maximum function. One extension of up to 14 calendar days may be allowed if the enrollee requests it or if the HMO justifies the need for more information. On the date that the timeframes expire, HMO gives notice that service authorization decisions are not reached. Untimely service authorizations constitute a denial and are thus adverse actions. 5. Criteria for decisions on coverage and medical necessity are clearly documented, are based on reasonable medical evidence, current standards of medical practice, or a consensus of relevant health care professionals, and are regularly updated. 6. The HMO oversees and is accountable for any functions and responsibilities that it delegates to any subcontractor. (See Article II Delegations of Authority). 7. Postpartum discharge policy for mothers and infants must be based on medical necessity determinations. This policy must include all follow-up tests and treatments consistent with currently accepted medical practice and applicable federal law. The policy must allow at least a 48-hour hospital stay for normal spontaneous vaginal delivery, and 96 hours for a cesarean section delivery, unless a shorter stay is agreed to by both the physician and the enrollee. HMOs may not deny coverage, penalize providers, or give incentives or payments to providers or enrollees. Post hospitalization follow-up care must be based on the medical needs and circumstances of the mother and infant. The Department may request documentation demonstrating compliance with this requirement.

Utilization Management (UM. 1. The HMO must have documented policies and procedures for all UM activities that involve determining medical necessity, and the approval or denial of medical services. Qualified medical 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 enrollee’s condition(s). 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 HFS 101.03 (96m) Wis. Adm. Code. 2. If the HMO delegates any part of the UM program to a third party, the delegation must meet the requirements in Article II Delegations of Authority. 3. If the HMO utilizes telephone triage, nurse lines or other demand management systems, the HMO 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. 4. The HMO’s policies must specify time frames for responding to requests for initial and continued service determinations, specify information required for authorization decisions, 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 HMO must have in effect mechanisms to ensure consistent application of review criteria for authorization decisions (interrater reliability). a. Within the time frames specified, the HMO must give the enrollee 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 enrollee’s right to file a grievance or request a state fair hearing. HMO Contract for February 1, 2006 - December 31, 2007. b. Authorization decisions must be made within the following time frames and in all cases as expeditiously as the enrollee’s condition requires: 1) Within 14 calendar days of the receipt of the request, or 2) Within three business days if the physician indicates or the HMO determines that following the ordinary time frame could jeopardize the enrollee’s health or ability to regain maximum function. One extension of up to 14 calendar days may be allowed if the enrollee requests it or if the HMO justifies the need for more information. On the date that the timeframes expire, HMO gives notice that service authorization decisions are not reached. Untimely service authorizations constitute a denial and are thus adverse actions. 5. Criteria for decisions on coverage and medical necessity are clearly documented, are based on reasonable medical evidence, current standards of medical practice, or a consensus of relevant health care professionals, and are regularly updated. 6. The HMO oversees and is accountable for any functions and responsibilities that it delegates to any subcontractor. (See Article II Delegations of Authority). 7. Postpartum discharge policy for mothers and infants must be based on medical necessity determinations. This policy must include all follow-up tests and treatments consistent with currently accepted medical practice and applicable federal law. The policy must allow at least a 48-hour hospital stay for normal spontaneous vaginal delivery, and 96 hours for a cesarean section delivery, unless a shorter stay is agreed to by both the physician and the enrollee. HMOs may not deny coverage, penalize providers, or give incentives or payments to providers or enrollees. Post hospitalization follow-up care must be based on the medical needs and circumstances of the mother and infant. The Department may request documentation demonstrating compliance with this requirement.