Common use of Underutilization of services Clause in Contracts

Underutilization of services. In order to ensure all Medicaid-covered services are provided, as required, monitoring of the following areas shall occur: 1. The MCOPs shall annually review their prior authorization (PA) procedures to determine if they unreasonably limit a member’s access to Medicaid-covered services; 2. The MCOP shall annually review their appeals process for providers following the MCOP’s denial of a prior authorization request for a determination as to whether the appeals process unreasonably limits a member’s access to Medicaid-covered services; 3. The MCOP shall monitor, on an ongoing basis, service denials, and utilization in order to identify member services which may be underutilized; and 4. If any underutilized services or limits to a member’s access to Medicaid-covered services are identified, the MCOP shall immediately investigate and, if indicated, correct the problem(s).