Utilization Management Programs Clause Samples

Utilization Management Programs. The MCP shall implement clearly defined structures and processes to maximize the effectiveness of the care provided to members pursuant to OAC rule 5160-26-03. a. The MCP will participate in clinical and policy collaborative workgroups as specified by ODM to identify methods for improvement in the standardization of prior authorization processes and standards for services determined by ODM. The MCP will ensure appropriate subject matter experts are included and adhere to timelines established by ODM. b. The MCP will participate in a clinical and policy collaborative workgroup to identify methods for improvement in the prior authorization processes and clinical standards for applied behavioral analysis (ABA) services. The MCP will ensure appropriate subject matter experts are included and adhere to timelines established by ODM. c. Pursuant to the criteria in ORC section 5160.34(C), the MCP is prohibited from retroactively denying a prior authorization (PA) request as a utilization management strategy. When performing a pre-payment review of a claim the MCP may not deny the claim due to medical necessity when the service was prior authorized. In addition, the MCP shall permit the retrospective review of a claim submitted for a service where PA was required, but not obtained, pursuant to the criteria in ORC section 5160.34(B)(9). Also, ORC section 5160.34 requires the MCPs establish a streamlined provider appeal process relating to adverse PA determinations.

Utilization Management Programs. The MCP shall implement clearly defined structures and processes to maximize the effectiveness of the care provided to members pursuant to OAC rule 5160-26-03.1. Pursuant to the criteria in ORC section 5160.34(C), the MCP is prohibited from retroactively denying a prior authorization (PA) request as a utilization management strategy. In addition, the MCP shall permit the retrospective review of a claim submitted for a service where PA was required, but not obtained, pursuant to the criteria in ORC section 5160.34(B)(9). Also ORC section 5160.34 requires the MCPs establish a streamlined provider appeal process relating to adverse PA determinations.

Utilization Management Programs. General Provisions - Pursuant to OAC rule 5101:3-26-03.1(A)(7), MCPs must implement a utilization management (UM) program to maximize the effectiveness of the care provided to members and may develop other UM programs, subject to prior approval by ODJFS. For the purposes of this requirement, the specific UM programs which require ODJFS prior-approval are an MCP’s general pharmacy program, a controlled substances and member management program, and any other program designed by the MCP with the purpose of redirecting or restricting access to a particular service or service location. i. Pharmacy Programs - Pursuant to ORC Sec. 5111.172 and OAC rule 5101:3-26-03(A) and (B), MCPs may, subject to ODJFS prior- approval, implement strategies for the management of pharmacy utilization. Pharmacy utilization management strategies may include developing preferred drug lists, requiring prior authorization for certain drugs, placing limitations on the type of provider and locations where certain medications may be administered, and developing and implementing a specialized pharmacy program to address the utilization of controlled substances, as defined in section 3719.01 of the Ohio Revised Code. Drug Prior Authorizations: MCPs must receive prior approval from ODJFS for the medications that they wish to cover through prior authorization. MCPs must establish their prior authorization system so that it does not unnecessarily impede member access to medically-necessary Medicaid-covered services. MCPs must make their approved list of drugs covered only with prior authorization available to members and providers, as outlined in paragraphs 37(b) and (c) of Appendix C. Beginning January 1, 2008, MCPs may require prior authorization for the coverage of antipsychotic drugs with ODJFS approval. MCPs must, however, allow any member to continue receiving a specific antipsychotic drug if the member is stabilized on that particular medication. The MCP must continue to cover that specific drug for the stabilized member for as long as that medication continues to be effective for the member. MCPs may also implement a drug utilization review program designed to promote the appropriate clinical prescribing of antipsychotic drugs. This can be accomplished through the MCP’s retrospective analysis of drug claims to identify potential inappropriate use and provide education to those providers who are outliers to acceptable standards for prescribing/dispensing antipsychotic drugs. MCPs must c...

Utilization Management Programs. In accordance with Sections 2.4 and 2.8 of the Three-Way, and OAC rules 5160-58-01.1 and 5160-26-03.1, the MCOP shall implement utilization management programs with clearly defined structures and processes to maximize the effectiveness of the care provided to dual benefits and Medicaid only members. Pursuant to the criteria in ORC Section 5160.34, the MCOP is prohibited from retroactively denying a prior authorization (PA) request as a utilization management strategy. In addition, the MCOP shall permit the retrospective review of a claim submitted for a service where PA was required, but not obtained, pursuant to the criteria in ORC Section 5160.34. In accordance with ORC Section 5160.34, the MCOP is required to establish a streamlined provider appeal process relating to adverse PA determinations. a. The MCOP will participate in clinical and policy collaborative workgroups as specified by ODM to identify methods for improvement in the standardization of prior authorization processes and standards for services determined by ODM. The MCOP will ensure appropriate subject matter experts are included and adhere to timelines established by ODM.

Utilization Management Programs. The MCP shall implement clearly defined structures and processes to maximize the effectiveness of the care provided to members pursuant to OAC rule 5160-26-03. a. The MCP will participate in clinical and policy collaborative workgroups as specified by ODM to identify methods for improvement in the standardization of prior authorization processes and standards for services determined by ODM. The MCP will ensure appropriate subject matter experts are included and adhere to timelines established by ODM. b. Pursuant to the criteria in ORC section 5160.34(C), the MCP is prohibited from retroactively denying a prior authorization (PA) request as a utilization management strategy. In addition, the MCP shall permit the retrospective review of a claim submitted for a service where PA was required, but not obtained, pursuant to the criteria in ORC section 5160.34(B)(9). Also, ORC section 5160.34 requires the MCPs establish a streamlined provider appeal process relating to adverse PA determinations.

Utilization Management Programs. In accordance with Sections 2.4 and 2.8 of the Three-Way, and OAC rules 5160-58-01.1 and 5160-26-03.1, the MCOP shall implement utilization management programs with clearly defined structures and processes to maximize the effectiveness of the care provided to dual benefits and Medicaid only members. Pursuant to the criteria in ORC Section 5160.34, the MCOP is prohibited from retroactively denying a prior authorization (PA) request as a utilization management strategy. In addition, the MCOP shall permit the retrospective review of a claim submitted for a service where PA was required, but not obtained, pursuant to the criteria in ORC Section 5160.34. In accordance with ORC Section 5160.34, the MCOP is required to establish a streamlined provider appeal process relating to adverse PA determinations.

Utilization Management Programs. General Provisions - Pursuant to OAC rule 5101:3-26-03.1(A)(7)(e), MCPs may implement utilization management programs, subject to prior approval by ODJFS. For the purposes of this requirement, utilization management programs are defined as programs designed by the MCP with the purpose of redirecting or restricting access to a particular service or service location. MCP care coordination and disease management activities which are designed to enhance the services provided to members with specific health care needs would not be considered utilization management programs nor would the designation of specific services requiring prior approval by the MCP or the member's PCP. Emergency Department Diversion (EDD) - MCPs must provide access to services in a way that assures access to primary, specialist and urgent care in the most appropriate settings and that minimizes frequent, preventable utilization of emergency department (ED) services. OAC rule 5101:3-26-03.1(A)(7)(e) requires MCPs to implement the ODJFS-required emergency department diversion (EDD) program for frequent utilizers. Each MCP must establish an ED diversion (EDD) program with the goal of minimizing frequent ED utilization. The MCP's EDD program must include the monitoring of ED utilization, identification of frequent ED utilizers, and targeted approaches designed to reduce avoidable ED utilization. MCP EDD programs must, at a minimum, address those ED visits which could have been prevented through improved education, access, quality or care management approaches. Although there is often an assumption that frequent ED visits are solely the result of a preference on the part of the member and education is therefore the standard remedy, it's also important to ensure that a member's frequent ED utilization is not due to problems such as their PCP's lack of accessibility or failure to make appropriate specialist referrals. The MCP's EDD diversion program must therefore also include the identification of providers who serve as PCPs for a substantial number of frequent ED utilizers and the implementation of corrective action with these providers as so indicated. This requirement does not replace the MCP's responsibility to inform and educate all members regarding the appropriate use of the ED. In accordance with Appendix C, MCP Responsibilities, MCPs must submit to ODJFS by September 1, 2003, for review and approval, a written description of the MCP's EDD program. Any subsequent changes to an approved ...

Utilization Management Programs. Managing the use of certain drugs is a key part of reining in the rising cost of care. Our utilization management (UM) programs offer the insight you need for greater control of why, how much and how often certain drugs are prescribed. Our UM programs give health care professionals guidance that supports appropriate drug use, keeping costs down for everyone, and improving member health and safety. We offer three primary types of UM programs, including step therapy, quantity limits, and prior authorizations described as follows:  Step therapy programs take a “step” approach to providing members a drug to help treat their condition. This means that members may first need to try a first-line drug before coverage is provided for a second-line drug. A first-line drug is usually a generic drug (or preferred brand if generics are not available) and represents a more cost-effective alternative for the member and Santa ▇▇▇▇ County School Board.  Quantity limits programs promote safe and effective drug use and reduce waste by limiting certain prescriptions to a pre-determined quantity limit or duration.  Prior authorization programs prevent misuse, overuse or inappropriate use by requiring members to meet certain criteria before particular drugs are covered. While cost savings may be achieved through these programs, they are recommended to enhance drug safety and member health.  Medical Drug Review helps capture improvements in outcomes, safety and savings that result from changes in drug management under the medical benefit through our Comprehensive Clinical Review (CCR) program Our generic programs help increase utilization rates and build awareness of cost savings for generic products. We will work closely with Santa ▇▇▇▇ County School Board on implementing the right benefit design and strategy for your business which may include member-focused communication strategies and reporting to identify and influence trends.  Outline and describe available formularies. Included pharmacy savings for each available formulary. BCBSF offers Santa ▇▇▇▇ County School Board the BCBSF Medication Guide formulary, which provides members with broad access to safe, medically necessary products. The formulary identifies those agents that are preferred based on a comprehensive evaluation of each drug’s comparative clinical efficacy, safety, uniqueness, and cost. The evaluation is performed by BCBSF and ▇▇▇▇▇'s National Pharmacy and Therapeutics (P&T) Committee, comprised of practi...

Utilization Management Programs. General Provisions - Pursuant to OAC rule 5101:3-26-03.1(A)(7), MCPs must implement a utilization management (UM) program to maximize the effectiveness of the care provided to members and may develop other UM programs, subject to prior approval by ODJFS. For the purposes of this requirement, the specific UM programs which require ODJFS prior-approval are an MCP’s general pharmacy program, a controlled substances and member management program, and any other program designed by the MCP with the purpose of redirecting or restricting access to a particular service or service location. i. Pharmacy Programs - Pursuant to ORC Sec. 5111.172, MCPs may, subject to ODJFS prior-approval, implement strategies for the management of drug utilization. Pharmacy utilization management strategies may include developing preferred drug lists, requiring prior authorization for certain drugs, placing limitations on the type of provider and locations where certain medications may be administered, and developing and implementing a specialized pharmacy program to address the utilization of controlled substances, as defined in section 3719.01 of the Ohio Revised Code. MCPs may also implement a retrospective drug utilization review program designed to promote the appropriate clinical prescribing of covered drugs. Drug Prior Authorizations: MCPs must receive prior approval from ODJFS for the medications that they wish to cover through prior authorization. MCPs must establish their prior authorization system so that it does not unnecessarily impede member access to medically-necessary Medicaid-covered