Common use of Utilization Management Clause in Contracts

Utilization Management. The Contractor shall maintain a utilization management plan and procedures consistent with the following: Staffing of all utilization management activities shall include, but not be limited to, a medical director, or medical director‘s designee. The Contractor shall also have a medical director‘s designee for Behavioral Health utilization management. All of the team members shall: Be in compliance with all federal, State, and local professional licensing requirements; Include representatives from appropriate specialty areas. Such specialty areas shall include, at a minimum, cardiology, epidemiology, OB/GYN, psychiatry, and substance use disorders; Have at least two (2) or more years of experience in managed care or peer review activities, or both; Not have had any disciplinary actions or other type of sanction ever taken against them, in any state or territory, by the relevant professional licensing or oversight board or the Medicare and Medicaid programs; and Not have any sanctions relating to his or her professional practice including, but not limited to, malpractice actions resulting in entry of judgment against him or her, unless otherwise agreed to by EOHHS; In addition to the requirements set forth in Section 2.9.4.4, the medical director‘s designee for Behavioral Health utilization management shall also: Be board-certified or board-eligible in psychiatry; and Be available twenty-four (24) hours per day, seven days a week for consultation and decision-making with the Contractor‘s clinical staff and providers. The Contractor shall have in place policies and procedures that at a minimum: Routinely assess the effectiveness and the efficiency of the utilization management program; Evaluate the appropriate use of medical technologies, including medical procedures, diagnostic procedures and technology, Behavioral Health treatments, pharmacy formularies and devices; Target areas of suspected inappropriate service utilization; Detect over- and under-utilization; Routinely generate provider profiles regarding utilization patterns and compliance with utilization review criteria and policies; Compare Enrollee and provider utilization with norms for comparable individuals and Network Providers; Routinely monitor inpatient admissions, emergency room use, ancillary, out-of-area services, and out-of-network services, as well as Behavioral Health inpatient and outpatient services, diversionary services, and ESPs; Ensure that treatment and discharge planning are addressed at the time of authorization and concurrent review, and that the treatment planning includes coordination with the PCP, other providers, and other supports identified by the Enrollee as appropriate; Conduct retrospective reviews of the medical records of selected cases to assess the medical necessity, clinical appropriateness of care, and the duration and level of care; Refer suspected cases of provider or Enrollee fraud or abuse to EOHHS; Address processes through which the Contractor monitors issues around services access and quality identified by the One Care Plan, EOHHS, Enrollees, and providers, including the tracking of these issues and resolutions over time; and Are communicated, accessible, and understandable to internal and external individuals, and entities, as appropriate. The Contractor‘s utilization management activities shall include: Referrals and coordination of Covered Services; Authorization of Covered Services, including modification or denial of requests for such services; Assisting providers to effectively provide inpatient Discharge Planning; Behavioral Health treatment and discharge planning; Monitoring and assuring the appropriate utilization of specialty services, including Behavioral Health Services; Providing training and supervision to the Contractor‘s utilization management clinical staff and Providers on: The standard application of medical necessity criteria and utilization management policies and procedures to ensure that staff maintain and improve their clinical skills; Utilization management policies, practices and data reported to the One Care Plan to ensure that it is standardized across all providers within the One Care Plan ‘s Provider Network; and The consistent application and implementation of the Contractor‘s clinical criteria and guidelines including the Behavioral Health clinical criteria approved by EOHHS. Monitoring and assessing all Contractor services and outcomes measurement, using any standardized clinical outcomes measurement tools to support utilization management activities; and Care management programs. Ensure that clinicians conducting utilization management who are coordinating Behavioral Health Services, and making Behavioral Health service authorization decisions, have training and experience in the specific area of Behavioral Health service for which they are coordinating and authorizing Behavioral Health Services. The Contractor shall ensure the following: That the clinician coordinating and authorizing mental health services shall be a clinician with experience and training in mental health services and recovery principles; That the clinician coordinating and authorizing substance use disorders shall be a clinician with experience and training in substance use disorders; and That the clinician coordinating and authorizing services for Enrollees with co-occurring disorders shall have experience and training in co-occurring disorders. The Contractor shall have policies and procedures for its approach to retrospective utilization review of providers. Such approach shall include a system to identify utilization patterns of all providers by significant data elements and established outlier criteria for all services. The Contractor shall have policies and procedures for conducting retrospective and peer reviews of a sample of providers to ensure that the services furnished by providers were provided to Enrollees, were appropriate and medically necessary, and were authorized and billed in accordance with the One Care Plan‘s requirements. The Contractor shall have policies and procedures for conducting monthly reviews of a random sample of no fewer than five hundred (500) Enrollees to ensure that such Enrollees received the services for which providers billed with respect to such Enrollees; and shall report the results of such review to EOHHS as requested. The Contractor shall not provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue Medically Necessary Services to any Enrollee. Submit an annual report of Enrollees who have been enrolled in the Contractor‘s Plan for one year or more with no utilization. The report shall include an explanation of outreach activities to engage these Enrollees. If utilization management review activities are performed for Clinical Support Services for Substance Use Disorders (Level III.5), such activities may be performed no earlier than day 7 of the provision of such services, provided, however, that the Contractor may not make any utilization review decisions that impose any restriction or deny any future medically necessary clinical stabilization services unless an Enrollee has received at least fourteen (14) consecutive days of clinical stabilization services. Any such decisions must follow the requirements set forth in Section 2.12 regarding the transmission of adverse determination notifications to Enrollees and clinicians and processes for internal and external Appeals of Contractor‘s decisions. The Contractor may not impose concurrent review and deny coverage for ATS based on utilization review; however, the Contractor may contact providers of ATS to discuss coordination of care, treatment plans, and after care.

Utilization Management. The Contractor shall maintain a utilization management plan and procedures consistent with the following: Staffing of all utilization management Utilization Management activities shall include, but not be limited to, a medical director, or medical director‘s director’s designee. The Contractor shall also have a medical director‘s director’s designee for Behavioral Health utilization managementbehavioral health Utilization Management. The Contractor’s accountable designee(s) and staff conducting Utilization Management activities applied to the One Care Plan shall be credentialed in Massachusetts, and shall be familiar with the Massachusetts delivery system, the standards and practices of care in Massachusetts, and best practices for service delivery, and shall be accountable to the One Care Plan’s local management team in Massachusetts. Such accountable designee for Utilization Management shall participate in the One Care Plan’s Consumer Advisory Committee. All of the Contractor’s Utilization Management team members members, including the accountable designees, shall: Be in compliance with all federal, State, and local professional licensing requirements; Include representatives from appropriate specialty areas. Such specialty areas shall include, at a minimum, cardiology, epidemiology, OB/GYN, psychiatry, and substance use disorders; Have at least two (2) or more years of experience in managed care or peer review activities, or both; Not have had any disciplinary actions or other type of sanction ever taken against them, in any state or territory, by the relevant professional licensing or oversight board or the Medicare and Medicaid programs; and Not have any sanctions relating to his or her professional practice including, but not limited to, malpractice actions resulting in entry of judgment against him or her, unless otherwise agreed to by EOHHS; In addition to the requirements set forth in Section 2.9.4.4, the medical director‘s director’s designee for Behavioral Health utilization management shall also: Be board-certified board‑certified or board-eligible board‑eligible in psychiatry; and Be available twenty-four twenty‑four (24) hours per day, seven days a week for consultation and decision-making decision‑making with the Contractor‘s Contractor’s clinical staff and providers. The Contractor shall have in place policies and procedures that at a minimum: Routinely assess the effectiveness and the efficiency of the utilization management program; Evaluate the appropriate use of medical technologies, including medical procedures, diagnostic procedures and technology, Behavioral Health treatments, pharmacy formularies and devices; Target areas of suspected inappropriate service utilization; Detect over- over‑ and under-utilizationunder‑utilization; Routinely generate provider profiles regarding utilization patterns and compliance with utilization review criteria and policies; Compare Enrollee and provider utilization with norms for comparable individuals and Network Providers; Routinely monitor inpatient admissions, emergency room use, ancillary, out-of-area out‑of‑area services, and out-of-network out‑of‑network services, as well as Behavioral Health inpatient and outpatient services, diversionary services, and ESPs; Ensure that treatment and discharge planning are addressed at the time of authorization and concurrent review, and that the treatment planning includes coordination with the PCP, other providers, and other supports identified by the Enrollee as appropriate; Conduct retrospective reviews of the medical records of selected cases to assess the medical necessity, clinical appropriateness of care, and the duration and level of care; Refer suspected cases of provider or Enrollee fraud or abuse to EOHHS; Address processes through which the Contractor monitors issues around services access and quality identified by the One Care Plan, EOHHS, Enrollees, and providers, including the tracking of these issues and resolutions over time; and Are communicated, accessible, and understandable to internal and external individuals, and entities, as appropriate. The Contractor‘s Contractor’s utilization management activities shall include: Referrals and coordination of Covered Services; Authorization of Covered Services, including modification or denial of requests for such services; Assisting providers to effectively provide inpatient Discharge Planning; Behavioral Health treatment and discharge planning; Monitoring and assuring the appropriate utilization of specialty services, including Behavioral Health Services; Providing training and supervision to the Contractor‘s Contractor’s utilization management clinical staff and Providers on: The standard application of medical necessity criteria and utilization management policies and procedures to ensure that staff maintain and improve their clinical skills; Utilization management policies, practices and data reported to the One Care Plan to ensure that it is standardized across all providers within the One Care Plan ‘s ’s Provider Network; and The consistent application and implementation of the Contractor‘s Contractor’s clinical criteria and guidelines including the Behavioral Health clinical criteria approved by EOHHS. Monitoring and assessing all Contractor services and outcomes measurement, using any standardized clinical outcomes measurement tools to support utilization management activities; and Care management programs. Ensure that clinicians conducting utilization management who are coordinating Behavioral Health Services, and making Behavioral Health service authorization decisions, have training and experience in the specific area of Behavioral Health service for which they are coordinating and authorizing Behavioral Health Services. The Contractor shall ensure the following: That the clinician coordinating and authorizing mental health services shall be a clinician with experience and training in mental health services and recovery principles; That the clinician coordinating and authorizing substance use disorders shall be a clinician with experience and training in substance use disorders; and That the clinician coordinating and authorizing services for Enrollees with co-occurring co‑occurring disorders shall have experience and training in co-occurring co‑occurring disorders. The Contractor shall have policies and procedures for its approach to retrospective utilization review of providers. Such approach shall include a system to identify utilization patterns of all providers by significant data elements and established outlier criteria for all services. The Contractor shall have policies and procedures for conducting retrospective and peer reviews of a sample of providers to ensure that the services furnished by providers were provided to Enrollees, were appropriate and medically necessary, and were authorized and billed in accordance with the One Care Plan‘s Plan’s requirements. The Contractor shall have policies and procedures for conducting monthly reviews of a random sample of no fewer than five hundred (500) Enrollees to ensure that such Enrollees received the services for which providers billed with respect to such Enrollees; and shall report the results of such review to EOHHS as requested. The Contractor shall not provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue Medically Necessary Services to any Enrollee. Submit an annual report of Enrollees who have been enrolled in the Contractor‘s Contractor’s Plan for one year or more with no utilization. The report shall include an explanation of outreach activities to engage these Enrollees. If utilization management review activities are performed for Clinical Support Services for Substance Use Disorders (Level III.5), such activities may be performed no earlier than day 7 of the provision of such services, provided, however, that the Contractor may not make any utilization review decisions that impose any restriction or deny any future medically necessary clinical stabilization services unless an Enrollee has received at least fourteen (14) consecutive days of clinical stabilization services. Any such decisions must follow the requirements set forth in Section 2.12 regarding the transmission of adverse determination notifications to Enrollees and clinicians and processes for internal and external Appeals of Contractor‘s Contractor’s decisions. The Contractor may not impose concurrent review and deny coverage for ATS based on utilization review; however, the Contractor may contact providers of ATS to discuss coordination of care, treatment plans, and after care.

Utilization Management. The Contractor shall maintain a utilization management Utilization Management plan and procedures consistent with the following: Staffing of all utilization management Utilization Management activities shall include, but not be limited to, a medical directorMedical Director, or medical director‘s Medical Director’s designee. The Contractor shall also have a medical director‘s Medical Director’s designee for Behavioral Health utilization managementUtilization Management. All of the team members shall: Be in compliance with all federal, State, and local professional licensing requirements; Include representatives from appropriate specialty areas. Such specialty areas shall include, at a minimum, cardiology, epidemiology, OB/GYN, psychiatry, and substance use disorders; Have at least two (2) or more years of experience in managed care or peer review activities, or both; Not have had any disciplinary actions or other type of sanction ever taken against them, in any state or territory, by the relevant professional licensing or oversight board or the Medicare and Medicaid programs; and Not have any legal sanctions relating to his or her professional practice including, but not limited to, malpractice actions resulting in entry of judgment against him or her, unless otherwise agreed to by EOHHS; . In addition to the requirements set forth in Section 2.9.4.42.9.D.1, the medical director‘s Medical Director’s designee for Behavioral Health utilization management Utilization Management shall also: Be board-certified or board-eligible in psychiatry; and Be available twenty-four (24) 24 hours per day, seven days a week for consultation and decision-making with the Contractor‘s Contractor’s clinical staff and providersProviders. The Contractor shall have in place policies and procedures that at a minimum: Routinely assess the effectiveness and the efficiency of the utilization management Utilization Management program; Evaluate the appropriate use of medical technologies, including medical procedures, diagnostic procedures and technology, Behavioral Health treatments, pharmacy formularies and devices; Target areas of suspected inappropriate service utilization; Detect over- and under-utilization; Routinely generate provider Provider profiles regarding utilization patterns and compliance with utilization review criteria and policies; Compare Enrollee and provider Provider utilization with norms for comparable individuals and Network Providers; Routinely monitor inpatient admissions, emergency room use, ancillary, out-of-area services, and out-of-network services, as well as Behavioral Health inpatient Inpatient and outpatient servicesOutpatient Services, diversionary servicesDiversionary Services, and ESPs; Ensure that treatment and discharge planning Discharge Planning are addressed at the time of authorization and concurrent review, and that the treatment planning includes coordination with the PCP, other providersProviders, and other supports identified by the Enrollee as appropriate; Conduct retrospective reviews of the medical records of selected cases to assess the medical necessityMedical Necessity, clinical appropriateness of care, and the duration and level of care; Refer suspected cases of provider Provider or Enrollee fraud Fraud or abuse Abuse to EOHHS; Address processes through which the Contractor monitors issues around services access and quality identified by the One Care PlanICO, EOHHS, Enrollees, and providersProviders, including the tracking of these issues and resolutions over time; and Are communicated, accessible, and understandable to internal and external individuals, and entities, as appropriate. The Contractor‘s utilization management Contractor’s Utilization Management activities shall include: Referrals and coordination of Covered Services; Authorization of Covered Services, including modification or denial of requests for such services; Assisting providers Providers to effectively provide inpatient Discharge Planning; Behavioral Health treatment and discharge planningDischarge Planning; Monitoring and assuring the appropriate utilization of specialty services, including Behavioral Health Services; Providing training and supervision to the Contractor‘s utilization management Contractor’s Utilization Management clinical staff and Providers on: The standard application of medical necessity Medical Necessity criteria and utilization management Utilization Management policies and procedures to ensure that staff maintain and improve their clinical skills; Utilization management Management policies, practices and data reported to the One Care Plan ICO to ensure that it is standardized across all providers Providers within the One Care Plan ‘s ICO’s Provider Network; and The consistent application and implementation of the Contractor‘s clinical criteria Contractor’s Clinical Criteria and guidelines including the Behavioral Health clinical criteria Clinical Criteria approved by EOHHS. Monitoring and assessing all Contractor services and outcomes measurement, using any standardized clinical outcomes measurement tools to support utilization management Utilization Management activities; and Care management programs. Ensure that clinicians conducting utilization management Utilization Management who are coordinating Behavioral Health Services, and making Behavioral Health service authorization decisions, have training and experience in the specific area of Behavioral Health service for which they are coordinating and authorizing Behavioral Health Services. The Contractor shall ensure the following: That the clinician coordinating and authorizing mental health services shall be a clinician with experience and training in mental health services and recovery principlesservices; That the clinician coordinating and authorizing substance use disorders shall be a clinician with experience and training in substance use disorders; and That the clinician coordinating and authorizing services for Enrollees with coCo-occurring disorders Occurring Disorders shall have experience and training in coCo-occurring disordersOccurring Disorders. The Contractor shall have policies and procedures for its approach to retrospective utilization review of providersProviders. Such approach shall include a system to identify utilization patterns of all providers Providers by significant data elements and established outlier criteria for all services. The Contractor shall have policies and procedures for conducting retrospective and peer reviews of a sample of providers Providers to ensure that the services furnished by providers Providers were provided to Enrollees, were appropriate and medically necessaryMedically Necessary, and were authorized and billed in accordance with the One Care Plan‘s ICO’s requirements. The Contractor shall have policies and procedures for conducting monthly reviews of a random sample of no fewer than five hundred (500) 500 Enrollees to ensure that such Enrollees received the services for which providers Providers billed with respect to such Enrollees; and shall report the results of such review to EOHHS as requested. The Contractor shall not provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue Medically Necessary Services to any Enrollee. Submit an annual report of Enrollees who have been enrolled in the Contractor‘s Plan for one year or more with no utilization. The report shall include an explanation of outreach activities to engage these Enrollees. If utilization management review activities are performed for Clinical Support Services for Substance Use Disorders (Level III.5), such activities may be performed no earlier than day 7 of the provision of such services, provided, however, that the Contractor may not make any utilization review decisions that impose any restriction or deny any future medically necessary clinical stabilization services unless an Enrollee has received at least fourteen (14) consecutive days of clinical stabilization services. Any such decisions must follow the requirements set forth in Section 2.12 regarding the transmission of adverse determination notifications to Enrollees and clinicians and processes for internal and external Appeals of Contractor‘s decisions. The Contractor may not impose concurrent review and deny coverage for ATS based on utilization review; however, the Contractor may contact providers of ATS to discuss coordination of care, treatment plans, and after care.

Utilization Management. The Contractor shall maintain a utilization management Utilization Management plan and procedures consistent with the following: Staffing of all utilization management Utilization Management activities shall include, but not be limited to, a medical directorMedical Director, or medical director‘s Medical Director’s designee. The Contractor shall also have a medical director‘s Medical Director’s designee for Behavioral Health utilization managementUtilization Management. All of the team members shall: Be in compliance with all federal, State, and local professional licensing requirements; Include representatives from appropriate specialty areas. Such specialty areas shall include, at a minimum, cardiology, epidemiology, OB/GYN, psychiatry, and substance use disorders; Have at least two (2) or more years of experience in managed care or peer review activities, or both; Not have had any disciplinary actions or other type of sanction ever taken against them, in any state or territory, by the relevant professional licensing or oversight board or the Medicare and Medicaid programs; and Not have any legal sanctions relating to his or her professional practice including, but not limited to, malpractice actions resulting in entry of judgment against him or her, unless otherwise agreed to by EOHHS; . In addition to the requirements set forth in Section 2.9.4.42.9.D.1, the medical director‘s Medical Director’s designee for Behavioral Health utilization management Utilization Management shall also: Be board-certified or board-eligible in psychiatry; and Be available twenty-four (24) 24 hours per day, seven days a week for consultation and decision-making with the Contractor‘s Contractor’s clinical staff and providersProviders. The Contractor shall have in place policies and procedures that at a minimum: Routinely assess the effectiveness and the efficiency of the utilization management Utilization Management program; Evaluate the appropriate use of medical technologies, including medical procedures, diagnostic procedures and technology, Behavioral Health treatments, pharmacy formularies and devices; Target areas of suspected inappropriate service utilization; Detect over- and under-utilization; Routinely generate provider Provider profiles regarding utilization patterns and compliance with utilization review criteria and policies; Compare Enrollee and provider Provider utilization with norms for comparable individuals and Network Providers; Routinely monitor inpatient admissions, emergency room use, ancillary, out-of-area services, and out-of-network services, as well as Behavioral Health inpatient Inpatient and outpatient servicesOutpatient Services, diversionary servicesDiversionary Services, and ESPs; Ensure that treatment and discharge planning Discharge Planning are addressed at the time of authorization and concurrent review, and that the treatment planning includes coordination with the PCP, other providersProviders, and other supports identified by the Enrollee as appropriate; Conduct retrospective reviews of the medical records of selected cases to assess the medical necessityMedical Necessity, clinical appropriateness of care, and the duration and level of care; Refer suspected cases of provider Provider or Enrollee fraud Fraud or abuse Abuse to EOHHS; Address processes through which the Contractor monitors issues around services access and quality identified by the One Care PlanICO, EOHHS, Enrollees, and providersProviders, including the tracking of these issues and resolutions over time; and Are communicated, accessible, and understandable to internal and external individuals, and entities, as appropriate. The Contractor‘s utilization management Contractor’s Utilization Management activities shall include: Referrals and coordination of Covered Services; Authorization of Covered Services, including modification or denial of requests for such services; Assisting providers Providers to effectively provide inpatient Discharge Planning; Behavioral Health treatment and discharge planningDischarge Planning; Monitoring and assuring the appropriate utilization of specialty services, including Behavioral Health Services; Providing training and supervision to the Contractor‘s utilization management Contractor’s Utilization Management clinical staff and Providers on: The standard application of medical necessity Medical Necessity criteria and utilization management Utilization Management policies and procedures to ensure that staff maintain and improve their clinical skills; Utilization management Management policies, practices and data reported to the One Care Plan ICO to ensure that it is standardized across all providers Providers within the One Care Plan ‘s ICO’s Provider Network; and The consistent application and implementation of the Contractor‘s clinical criteria Contractor’s Clinical Criteria and guidelines including the Behavioral Health clinical criteria Clinical Criteria approved by EOHHS. Monitoring and assessing all Contractor services and outcomes measurement, using any standardized clinical outcomes measurement tools to support utilization management Utilization Management activities; and Care management programs. Ensure that clinicians conducting utilization management Utilization Management who are coordinating Behavioral Health Services, and making Behavioral Health service authorization decisions, have training and experience in the specific area of Behavioral Health service for which they are coordinating and authorizing Behavioral Health Services. The Contractor shall ensure the following: That the clinician coordinating and authorizing mental health services shall be a clinician with experience and training in mental health services and recovery principlesservices; That the clinician coordinating and authorizing substance use disorders shall be a clinician with experience and training in substance use disorders; and That the clinician coordinating and authorizing services for Enrollees with coCo-occurring disorders Occurring Disorders shall have experience and training in coCo-occurring disordersOccurring Disorders. The Contractor shall have policies and procedures for its approach to retrospective utilization review of providersProviders. Such approach shall include a system to identify utilization patterns of all providers Providers by significant data elements and established outlier criteria for all services. The Contractor shall have policies and procedures for conducting retrospective and peer reviews of a sample of providers Providers to ensure that the services furnished by providers Providers were provided to Enrollees, were appropriate and medically necessaryMedically Necessary, and were authorized and billed in accordance with the One Care Plan‘s ICO’s requirements. The Contractor shall have policies and procedures for conducting monthly reviews of a random sample of no fewer than five hundred (500) 500 Enrollees to ensure that such Enrollees received the services for which providers Providers billed with respect to such Enrollees; and shall report the results of such review to EOHHS as requested. The Contractor shall not provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue Medically Necessary Services to any Enrollee. Submit an annual report of Enrollees who have been enrolled in the Contractor‘s Contractor’s Plan for one year or more with no utilization. The report shall include an explanation of outreach activities to engage these Enrollees. If Effective October 1, 2015, if utilization management review activities are performed for Clinical Support Services for Substance Use Disorders (Level III.5), such activities may be performed no earlier than day 7 of the provision of such services, provided, however, that the Contractor may not make any utilization review decisions that impose any restriction or deny any future medically necessary clinical stabilization services unless an Enrollee has received at least fourteen (14) 14 consecutive days of clinical stabilization services. Any such decisions must follow the requirements set forth in Section 2.12 regarding the transmission of adverse determination notifications to Enrollees and clinicians and processes for internal and external Appeals appeals of Contractor‘s Contractor’s decisions. The Effective October 1, 2015, the Contractor may not impose concurrent review and deny coverage for ATS based on utilization review; however, the Contractor may contact providers of ATS to discuss coordination of care, treatment plans, and after care. Effective October 1, 2015, the Contractor may not establish utilization management strategies that require enrollees to “fail-first” or participate in “step therapy” as a condition of providing coverage for injectable naltrexone (Vivitrol™). Contractor must cover Vivitrol™ as a pharmacy and medical benefit.”

Utilization Management. The Contractor shall maintain a utilization management plan and procedures consistent with the following: Staffing of all utilization management activities shall include, but not be limited to, a medical director, or medical director‘s director’s designee. The Contractor shall also have a medical director‘s director’s designee for Behavioral Health utilization management. All of the team members shall: Be in compliance with all federal, State, and local professional licensing requirements; Include representatives from appropriate specialty areas. Such specialty areas shall include, at a minimum, cardiology, epidemiology, OB/GYN, psychiatry, and substance use disorders; Have at least two (2) or more years of experience in managed care or peer review activities, or both; Not have had any disciplinary actions or other type of sanction ever taken against them, in any state or territory, by the relevant professional licensing or oversight board or the Medicare and Medicaid programs; and Not have any sanctions relating to his or her professional practice including, but not limited to, malpractice actions resulting in entry of judgment against him or her, unless otherwise agreed to by EOHHS; In addition to the requirements set forth in Section 2.9.4.4, the medical director‘s director’s designee for Behavioral Health utilization management shall also: Be board-certified board‑certified or board-eligible board‑eligible in psychiatry; and Be available twenty-four twenty‑four (24) hours per day, seven days a week for consultation and decision-making decision‑making with the Contractor‘s Contractor’s clinical staff and providers. The Contractor shall have in place policies and procedures that at a minimum: Routinely assess the effectiveness and the efficiency of the utilization management program; Evaluate the appropriate use of medical technologies, including medical procedures, diagnostic procedures and technology, Behavioral Health treatments, pharmacy formularies and devices; Target areas of suspected inappropriate service utilization; Detect over- over‑ and under-utilizationunder‑utilization; Routinely generate provider profiles regarding utilization patterns and compliance with utilization review criteria and policies; Compare Enrollee and provider utilization with norms for comparable individuals and Network Providers; Routinely monitor inpatient admissions, emergency room use, ancillary, out-of-area out‑of‑area services, and out-of-network out‑of‑network services, as well as Behavioral Health inpatient and outpatient services, diversionary services, and ESPs; Ensure that treatment and discharge planning are addressed at the time of authorization and concurrent review, and that the treatment planning includes coordination with the PCP, other providers, and other supports identified by the Enrollee as appropriate; Conduct retrospective reviews of the medical records of selected cases to assess the medical necessity, clinical appropriateness of care, and the duration and level of care; Refer suspected cases of provider or Enrollee fraud or abuse to EOHHS; Address processes through which the Contractor monitors issues around services access and quality identified by the One Care Plan, EOHHS, Enrollees, and providers, including the tracking of these issues and resolutions over time; and Are communicated, accessible, and understandable to internal and external individuals, and entities, as appropriate. The Contractor‘s Contractor’s utilization management activities shall include: Referrals and coordination of Covered Services; Authorization of Covered Services, including modification or denial of requests for such services; Assisting providers to effectively provide inpatient Discharge Planning; Behavioral Health treatment and discharge planning; Monitoring and assuring the appropriate utilization of specialty services, including Behavioral Health Services; Providing training and supervision to the Contractor‘s Contractor’s utilization management clinical staff and Providers on: The standard application of medical necessity criteria and utilization management policies and procedures to ensure that staff maintain and improve their clinical skills; Utilization management policies, practices and data reported to the One Care Plan to ensure that it is standardized across all providers within the One Care Plan ‘s ’s Provider Network; and The consistent application and implementation of the Contractor‘s Contractor’s clinical criteria and guidelines including the Behavioral Health clinical criteria approved by EOHHS. Monitoring and assessing all Contractor services and outcomes measurement, using any standardized clinical outcomes measurement tools to support utilization management activities; and Care management programs. Ensure that clinicians conducting utilization management who are coordinating Behavioral Health Services, and making Behavioral Health service authorization decisions, have training and experience in the specific area of Behavioral Health service for which they are coordinating and authorizing Behavioral Health Services. The Contractor shall ensure the following: That the clinician coordinating and authorizing mental health services shall be a clinician with experience and training in mental health services and recovery principles; That the clinician coordinating and authorizing substance use disorders shall be a clinician with experience and training in substance use disorders; and That the clinician coordinating and authorizing services for Enrollees with co-occurring co‑occurring disorders shall have experience and training in co-occurring co‑occurring disorders. The Contractor shall have policies and procedures for its approach to retrospective utilization review of providers. Such approach shall include a system to identify utilization patterns of all providers by significant data elements and established outlier criteria for all services. The Contractor shall have policies and procedures for conducting retrospective and peer reviews of a sample of providers to ensure that the services furnished by providers were provided to Enrollees, were appropriate and medically necessary, and were authorized and billed in accordance with the One Care Plan‘s Plan’s requirements. The Contractor shall have policies and procedures for conducting monthly reviews of a random sample of no fewer than five hundred (500) Enrollees to ensure that such Enrollees received the services for which providers billed with respect to such Enrollees; and shall report the results of such review to EOHHS as requested. The Contractor shall not provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue Medically Necessary Services to any Enrollee. Submit an annual report of Enrollees who have been enrolled in the Contractor‘s Contractor’s Plan for one year or more with no utilization. The report shall include an explanation of outreach activities to engage these Enrollees. If utilization management review activities are performed for Clinical Support Services for Substance Use Disorders (Level III.5), such activities may be performed no earlier than day 7 of the provision of such services, provided, however, that the Contractor may not make any utilization review decisions that impose any restriction or deny any future medically necessary clinical stabilization services unless an Enrollee has received at least fourteen (14) consecutive days of clinical stabilization services. Any such decisions must follow the requirements set forth in Section 2.12 regarding the transmission of adverse determination notifications to Enrollees and clinicians and processes for internal and external Appeals of Contractor‘s Contractor’s decisions. The Contractor may not impose concurrent review and deny coverage for ATS based on utilization review; however, the Contractor may contact providers of ATS to discuss coordination of care, treatment plans, and after care.

Utilization Management. The Contractor shall maintain a utilization management plan and procedures consistent with the following: Staffing of all utilization management activities shall include, but not be limited to, a medical director, or medical director‘s director’s designee. The Contractor shall also have a medical director‘s director’s designee for Behavioral Health utilization management. All of the team members shall: Be in compliance with all federal, State, and local professional licensing requirements; Include representatives from appropriate specialty areas. Such specialty areas shall include, at a minimum, cardiology, epidemiology, OB/GYN, psychiatry, and substance use disorders; Have at least two (2) or more years of experience in managed care or peer review activities, or both; Not have had any disciplinary actions or other type of sanction ever taken against them, in any state or territory, by the relevant professional licensing or oversight board or the Medicare and Medicaid programs; and Not have any sanctions relating to his or her professional practice including, but not limited to, malpractice actions resulting in entry of judgment against him or her, unless otherwise agreed to by EOHHS; In addition to the requirements set forth in Section 2.9.4.4, the medical director‘s director’s designee for Behavioral Health utilization management shall also: Be board-certified or board-eligible in psychiatry; and Be available twenty-four (24) hours per day, seven days a week for consultation and decision-making with the Contractor‘s Contractor’s clinical staff and providers. The Contractor shall have in place policies and procedures that at a minimum: Routinely assess the effectiveness and the efficiency of the utilization management program; Evaluate the appropriate use of medical technologies, including medical procedures, diagnostic procedures and technology, Behavioral Health treatments, pharmacy formularies and devices; Target areas of suspected inappropriate service utilization; Detect over- and under-utilization; Routinely generate provider profiles regarding utilization patterns and compliance with utilization review criteria and policies; Compare Enrollee and provider utilization with norms for comparable individuals and Network Providers; Routinely monitor inpatient admissions, emergency room use, ancillary, out-of-area services, and out-of-network services, as well as Behavioral Health inpatient and outpatient services, diversionary services, and ESPs; Ensure that treatment and discharge planning are addressed at the time of authorization and concurrent review, and that the treatment planning includes coordination with the PCP, other providers, and other supports identified by the Enrollee as appropriate; Conduct retrospective reviews of the medical records of selected cases to assess the medical necessity, clinical appropriateness of care, and the duration and level of care; Refer suspected cases of provider or Enrollee fraud or abuse to EOHHS; Address processes through which the Contractor monitors issues around services access and quality identified by the One Care Plan, EOHHS, Enrollees, and providers, including the tracking of these issues and resolutions over time; and Are communicated, accessible, and understandable to internal and external individuals, and entities, as appropriate. The Contractor‘s Contractor’s utilization management activities shall include: Referrals and coordination of Covered Services; Authorization of Covered Services, including modification or denial of requests for such services; Assisting providers to effectively provide inpatient Discharge Planning; Behavioral Health treatment and discharge planning; Monitoring and assuring the appropriate utilization of specialty services, including Behavioral Health Services; Providing training and supervision to the Contractor‘s Contractor’s utilization management clinical staff and Providers on: The standard application of medical necessity criteria and utilization management policies and procedures to ensure that staff maintain and improve their clinical skills; Utilization management policies, practices and data reported to the One Care Plan to ensure that it is standardized across all providers within the One Care Plan ‘s ’s Provider Network; and The consistent application and implementation of the Contractor‘s Contractor’s clinical criteria and guidelines including the Behavioral Health clinical criteria approved by EOHHS. Monitoring and assessing all Contractor services and outcomes measurement, using any standardized clinical outcomes measurement tools to support utilization management activities; and Care management programs. Ensure that clinicians conducting utilization management who are coordinating Behavioral Health Services, and making Behavioral Health service authorization decisions, have training and experience in the specific area of Behavioral Health service for which they are coordinating and authorizing Behavioral Health Services. The Contractor shall ensure the following: That the clinician coordinating and authorizing mental health services shall be a clinician with experience and training in mental health services and recovery principles; That the clinician coordinating and authorizing substance use disorders shall be a clinician with experience and training in substance use disorders; and That the clinician coordinating and authorizing services for Enrollees with co-occurring disorders shall have experience and training in co-occurring disorders. The Contractor shall have policies and procedures for its approach to retrospective utilization review of providers. Such approach shall include a system to identify utilization patterns of all providers by significant data elements and established outlier criteria for all services. The Contractor shall have policies and procedures for conducting retrospective and peer reviews of a sample of providers to ensure that the services furnished by providers were provided to Enrollees, were appropriate and medically necessary, and were authorized and billed in accordance with the One Care Plan‘s Plan’s requirements. The Contractor shall have policies and procedures for conducting monthly reviews of a random sample of no fewer than five hundred (500) Enrollees to ensure that such Enrollees received the services for which providers billed with respect to such Enrollees; and shall report the results of such review to EOHHS as requested. The Contractor shall not provide that compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue Medically Necessary Services to any Enrollee. Submit an annual report of Enrollees who have been enrolled in the Contractor‘s Contractor’s Plan for one year or more with no utilization. The report shall include an explanation of outreach activities to engage these Enrollees. If utilization management review activities are performed for Clinical Support Services for Substance Use Disorders (Level III.5), such activities may be performed no earlier than day 7 of the provision of such services, provided, however, that the Contractor may not make any utilization review decisions that impose any restriction or deny any future medically necessary clinical stabilization services unless an Enrollee has received at least fourteen (14) consecutive days of clinical stabilization services. Any such decisions must follow the requirements set forth in Section 2.12 regarding the transmission of adverse determination notifications to Enrollees and clinicians and processes for internal and external Appeals of Contractor‘s Contractor’s decisions. The Contractor may not impose concurrent review and deny coverage for ATS based on utilization review; however, the Contractor may contact providers of ATS to discuss coordination of care, treatment plans, and after care.