UTILIZATION MANAGEMENT (UM) POLICY AND PROCEDURE MANUAL

Transcription

1 University of Florida, Pediatric Integrated Care System UTILIZATION MANAGEMENT (UM) POLICY AND PROCEDURE MANUAL Policy: Delegated Entity: Program(s): Utilization Management Ped-I-Care Title XIX and Title XXI Effective Date: May 1, 2007 Approved by: Title Name Signature Medical Director Executive Director Dates Revised Don Fillipps, MD Leslie Herndon, MBA, CPC, CMPE 10/30/2008, 1/5/2010, 7/23/2010, 3/28/2011, 10/7/2012, 11/25/2012, 4/30/2014, 2/2/2015, 2/17/2017 Ped-I-Care Approved 11/4/2008, 6/15/2015, 2/17/2017 Responsible Parties: Medical Director, Assistant Director for Utilization Management, Executive Director, MED3000, and Children s Medical Services Managed Care Plan (CMS Plan) Contract(s): 2014 Medicaid MMA Contract and 2013 Title XXI Contract Contract Service(s): Title XIX VII. G. Title XXI - Attachment VII, 6. and 9. e. Statutes CFR parts 438 and 456 Associated Policies 1. Utilization Management Program Description Utilization Management Page 1 of 7

2 Purpose To establish policy and procedures that ensure utilization decisions are made in a timely manner to accommodate the clinical urgency of the situation. Policy 1. Ped-I-Care makes utilization decisions in a timely manner to accommodate the clinical urgency of the situation. 2. Concurrent review is handled by Ped-I-Care s TPA, MED3000. See MED3000 s policy # NS-HES Inpatient Review Policy. 3. Medically necessary inpatient hospital services, consistent with the provision of appropriate medical care, can not be effectively furnished more economically in an outpatient setting. Medical Directors and MED3000 Concurrent Reviews ensure compliance with this standard. 4. CMS Plan is responsible for the care management and disease management of Ped-I-Care members. See the CMS Plan Care Coordination Guidelines for more detailed information. Procedures 1. General Requirements a. Please refer to the Utilization Management Program Description for more detailed information. b. The UM program is consistent with 42 CFR 438 and 456 as applicable and includes, but is not limited to: (1) Procedures for identifying patterns of over-utilization and under-utilization of services and for addressing potential problems identified as a result of these analyses. (2) Reporting fraud and abuse information identified through the UM program to AHCA s MPI as described in Section VIII of the AHCA contract, and referenced in 42 CFR 455.1(a)(1) for Title XIX and to CMS Plan for Title XXI. (3) A procedure for members to obtain a second medical opinion and for CMS Plan to authorize claims for such services in accordance with s , F.S. and 42 CFR (b)(3). See MED3000 s policy # NS-HES Second Opinion for additional information. Utilization Management Page 2 of 7

3 (4) A procedure for the authorization of any medically necessary service to members under the age of twenty-one (21) years for Title 19 and nineteen (19) years for Title 21, in accordance with Section 1905(a) of the Social Security Act, when: i. The service is not listed in the service-specific Medicaid Coverage and Limitations Handbook, Florida Medicaid Coverage Policy, or the associated Florida Medicaid fee schedule, or is not a covered service of the plan; or ii. The amount, frequency, or duration of the service exceeds the limitations specified in the service-specific handbook or the corresponding fee schedule. (5) Requiring prior authorization for all non-emergency inpatient hospital admissions. (6) Protocols for prior authorization and denial of services; the process used to evaluate prior and concurrent authorization; objective evidence-based criteria to support authorization decisions; mechanisms to ensure consistent application of review criteria for authorization decisions; consultation with the requesting provider when appropriate; hospital discharge planning; physician profiling; mechanisms that allow network providers to advocate on behalf of members within the UM process; and a retrospective review of both inpatient and ambulatory claims, meeting the predefined criteria below. See MED3000 s policies # NS-HES Inpatient Review Policy, # NS-HES Hospital Discharge Planning, and # NS-HES Medical Review Process for additional information. i. CMS Plan and Ped-I-Care have written approval from AHCA for Title XIX and CMS Plan for Title XXI for service authorization protocols and will obtain written approval for any changes. ii. Ped-I-Care complies with AHCA s timeliness standards as outlined in Section VII. 2. of the AHCA prime contract. iii. Ped-I-Care's automated service authorization system, through MED3000, provides the authorization number and effective dates for authorization to providers and non-participating providers, and does not require paper authorization in addition as a condition for providing treatment. iv. Ped-I-Care's service authorization system provides written confirmation of all denials of authorization to providers (See 42 CFR (c)). (a) MED3000 notifies providers that an authorization request is denied. (b) Ped-I-Care sends members, providers, and nurse care coordinators written notification of denials or reductions in services. v. Ped-I-Care requests to be notified, but CMS Plan does not deny claims payment based solely on lack of notification, for the following: (a) Inpatient emergency admissions (within ten [10] calendar days), Utilization Management Page 3 of 7

4 (b) Obstetrical care (at first visit), (c) Obstetrical admissions exceeding forty-eight (48) hours for vaginal delivery and ninety-six (96) hours for caesarean section, and (d) Transplants. vi. Ped-I-Care ensures that all decisions to deny a service authorization request, or limit a service in amount, duration, or scope that is less than requested, are made by health care professionals who have the appropriate clinical expertise in treating the member s condition or disease (see 42 CFR (b)(3)). (a) Denial decisions are only made by Ped-I-Care Medical Directors (physicians). (b) Medical Directors consult providers with expertise in the area of the request when needed. (c) Denial decisions are determined using the acceptable standards of care, state and federal laws, AHCA s medical necessity definition, and clinical judgment of a licensed physician, psychiatrist, or dentist, as appropriate, or other professional as approved by AHCA. vii. Only a licensed psychiatrist authorizes a denial for an initial or concurrent authorization of any request for behavioral health services. The psychiatrist's review is part of the UM process and not part of the clinical review, which may be requested by a provider or the member, after the issuance of a denial. (a) Denial decisions for behavioral health services are only made by Ped-I-Care s contracted vendor s (Concordia Behavioral Health) licensed psychiatrist consultant. viii. Ped-I-Care provides post authorization to County Health Departments for emergency shelter medical screenings provided for DCF clients. ix. Ped-I-Care, through MED3000, has an automated authorization system as required in s (2)(c)3., FS and does not require paper authorization as a condition for providing treatment. (a) If paper authorizations are used, Ped-I-Care will use only the prior authorization form adopted by the Office of Insurance Regulation, pursuant to s , F.S. x. Ped-I-Care provides timely approval, reduction, or denial of authorization of outof-network use of non-emergency services. An approved service is assigned an authorization number which refers to and documents the approval. Written documentation of the approval is provided to the non-participating provider within one (1) business day after the approval. Utilization Management Page 4 of 7

5 xi. Ped-I-Care processes service authorizations within the contracted timeframes set forth by AHCA. However, the CMS Plan is not required to approve claims for which it has received no documentation to support the medical need of the service requested. xii. For those Title XXI members assigned to Ped-I-Care and who are dually enrolled in the Early Steps Program, the Individualized Family Support Plan (IFSP) is the authorizing document for all Early Steps services, except Durable Medical Equipment (DME). Ped-I-Care s consultant reviews DME requests for medical necessity. c. Compensation to individuals or entities that conduct UM activities is not structured to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any member. d. Title XIX and Title XXI authorization requirements may be accessed online under Forms at Requirements-July pdf 2. Practice Guidelines a. Ped-I-Care uses practice guidelines that are applicable to children with special health care needs. The guidelines are available at Ped-I-Care s practice guidelines meet the following requirements: (1) Are based on valid and reliable clinical evidence or a consensus of health care professionals in a particular field (2) Consider the needs of the members; (3) Are adopted in consultation with providers; and (4) Are reviewed and updated periodically, as appropriate (See 42 CFR (b)). b. Ped-I-Care disseminates any revised practice guidelines to all affected providers and, upon request, to members and potential members. c. Ped-I-Care ensures consistency with regard to all decisions relating to UM, covered services, and other areas applicable to Ped-I-Care to which the practice guidelines apply. CMS Plan ensures consistency with regard to member education by the NCC and other areas applicable to CMS Plan to which the practice guidelines apply. 3. Changes to Utilization Management Components a. Ped-I-Care provides no less than thirty (30) calendar days written notice to AHCA for Title XIX and forty (40) calendar days for Title XXI to CMS Plan before making any changes to the administration and/or management procedures and/or authorization, Utilization Management Page 5 of 7

6 denial, or review procedures, including any delegations, as described in this section of the AHCA contract for Title XIX and the CMS Plan contract for Title XXI. b. Ped-I-Care obtains written approval from AHCA for Title XIX and CMS Plan for Title XXI for its service authorization protocols and any changes. 4. New Members (Continuity of Care for Title 19 Members) a. Ped-I-Care honors any written documentation of prior authorization of ongoing covered services (including services provided by non-participating providers) for a period of sixty (60) calendar days after the effective date of enrollment, or until the member's PCP reviews the member's treatment plan, whichever comes first. b. Ped-I-Care, through its contracted vendor Concordia Behavioral Health, honors any written documentation of prior authorization of ongoing covered behavioral health services (including services provided by non-participating providers) for a period of sixty (60) days or until the member s PCP or behavioral health provider reviews the member s treatment plan, whichever comes first. c. The following services may extend beyond the continuity of care period, and Ped-I-Care will continue the entire course of treatment with the member s current provider as described below: (1) Prenatal and postpartum care [six (6) weeks after birth] (2) Transplant services [for one (1) year post-transplant] (3) Oncology (4) Full course of therapy Hepatitis C treatment drugs (Per CMS Plan and the appropriate delegated entity for pharmacy authorizations) d. For all members, written documentation of prior authorization of ongoing services includes the following, provided that the services were prearranged prior to enrollment with Ped-I-Care: (1) Prior existing orders; (2) Provider appointments, e.g. dental appointments, surgeries, etc.; and (3) Prescriptions (including prescriptions at non-participating pharmacies). CMS Plan is responsible, via delegated entities, for the outpatient pharmacy program. Please see the Prescription Drugs policy for more information. (a) Magellan is responsible for covering Title XIX medications and MedImpact is responsible for covering Title XXI medications. (b) CMS Plan reviews prescriptions for medical necessity and if medications are not in the applicable formulary, the NCC contacts Magellan for Title XIX and MedImpact for Title XXI to request an exception. If Magellan or MedImpact Utilization Management Page 6 of 7

7 denies the exception, the NCC contacts the provider to prescribe another drug that is in the applicable formulary. (4) Ped-I-Care processes service authorizations within the contracted timeframes set forth by AHCA. However, the CMS Plan is not required to approve claims for which it has received no documentation to support the medical need of the service requested. 5. Certain Public Providers (see the Access to Services policy for requirements related to certain public providers). Utilization Management Page 7 of 7