Common use of Utilization Management Programs Clause in Contracts

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 EDD program must be submitted to ODJFS in writing for review and approval prior to implementation.

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 =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 ’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 ’s also important to ensure that a member's ’s frequent ED utilization is not due to problems such as their PCP's ’s lack of accessibility or failure to make appropriate specialist referrals. The MCP's ’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 ’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 ’s EDD program. Any subsequent changes to an approved EDD program must be submitted to ODJFS in writing for review and approval prior to implementation.