Summary Of Utilization Management Process, Guidelines And Criteria
The materials provided to you are guidelines used by this plan to authorize, modify or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.
The Holman Group is committed to providing high quality mental health services, and strives toward excellence in customer service. It is our desire to help the client reduce functional impairments and to quickly improve daily functioning. It is also our goal to deliver quality and cost-effective mental health services through the effective use of resources, while measuring outcomes and satisfaction via continuous quality improvement methodologies.
The function of Utilization Management is to facilitate the provision of quality, efficient mental health services to clients and providers through monitoring, evaluating and influencing the processes and behaviors which impact the delivery of services. Managing the treatment patterns of the delivery systems for maximum efficiency is the overall goal of Utilization Management.
Accessing Services and Making Referrals
The Holman Group benefits, (inpatient, detoxification, alternative care and outpatient services), require pre-authorization, except for services provided on an emergency basis. In the case of emergency treatment, it is required that the facility, provider, enrollee, or a member of the enrollee's family contact The Holman Group on the following business day to notify Care Management of the emergency services rendered.
Urgently needed and emergency services can be authorized either by a Care Manager, if during business hours, or by an on-call crisis clinician, if after hours. The enrollee, the enrollee's representative or the provider can contact The Holman Group; the situation is assessed over the phone by the Care Manager or on-call clinician, and if appropriate, the enrollee is referred to and authorized for the necessary services at that time.
Providers seeing patients who need to make additional referrals for that patient (such as an MFT provider referring a patient to a psychiatrist) must contact The Holman Group Care Manager for that patient, giving justification for the referral request. If the referral is determined as appropriate, the Care Manager will make the assignment to the new/additional provider, relaying pertinent information about the patient, and will ensure that the appropriate authorization is given.
Authorization Decisions: Initial and Concurrent Review
Initial, concurrent and retroactive authorization decisions are made by Care Managers. Initial treatment authorization decisions are made at the time that the assessment and treatment plan are reviewed with the provider. Providers are verbally notified at that time of the initial authorization and will also be notified by mail in the form of a Notification of Authorization.
Client treatment progress and requests for continuing treatment authorizations are reviewed concurrently. Renewal requests are reviewed by Care Management staff for client progress, the continuing presence of impairments in functioning and crisis situations, and adherence to the treatment plan.
Retroactive Reviews
Most services received through The Holman Group require pre-authorization. However, on occasions a retroactive treatment authorization will be appropriate and necessary. When retroactive requests are received, they are reviewed for authorization by a Senior Care Manager or the Medical Director.
When clients are treated for emergency situations (such as being admitted through an emergency room for suicidal ideation with intent and plan), which are treated without authorization, the facility or the client's representative should contact Care Management no later than the following business day. Services will be authorized if these benefits are contracted for by the employer or contracting agency, and if the functional impairments and severity of risk factors justify the level of treatment.
Processes and Criteria Used to Authorize or Deny Services
The clinical review guidelines and McKesson criteria utilized by The Holman Group are based on national standards for mental health professional practice, which include the fields of psychiatry, clinical psychology, clinical social work, marriage, family and child counseling; and psychiatric nursing. These Guidelines were developed using clinical resources from (but not limited to) the American Psychiatric Association, American Medical Association, American Psychological Association, National Institute of Mental Health, National Institute of Alcohol Abuse and Alcoholism, and the National Institute of Drug Abuse.
These guidelines define the general criteria * used to determine the level of care and type of treatment needed for each case. The criteria include medical necessity, impairment of functioning, severity of risk factors, and level of care required to effectively treat the patient's problem. Authorization decisions are also influenced by the unique characteristics of each individual benefit package (which determine the available benefit), and the specific limitations of each plan.
Implicit in these guidelines is The Holman Group's goal to provide the most effective, appropriate level of care in the least restrictive (intensive) environment, and within the benefit package purchased by the client organization. This also requires that all patients have ready access to the covered services they need and that they receive quality treatment.
Medical Necessity
The central consideration in all The Holman Group clinical review decisions and authorizations is the determination of the most appropriate and medically necessary level of care. Clinical information gathered by The Holman Group's care management staff is aimed at satisfying this consideration.
The following conditions must be present in order to meet the criteria for medical necessity:
- Services are adequate and essential for the evaluation and treatment of a disease, condition or illness, as defined by standard diagnostic nomenclatures (DSM-IV, ICD-10);
- Treatment can be reasonably expected to improve an individual's condition or level of functioning;
- Evaluation and treatment methods are in keeping with national standards of mental health professional practice, using methods of treatment or evaluation for which there is an adequate basis in research;
- Are provided at the most cost effective level of care that is appropriate to the clinical needs of the patient.
To maintain authorization of benefits, all four elements of medical necessity must be present throughout the course of treatment.
Notification of Authorizations and Denials to Providers and Enrollees
Providers receive written notification of authorizations for all services authorized. Providers receive a written Notification of Authorization describing the services, number of units (sessions, days, etc.) and the time period authorized.
For enrollees receiving higher levels of care, authorizations and denials are communicated to the provider via phone, and are followed by a written Notification of Authorization. When appropriate, these decisions are communicated to the enrollee directly by the care manager; when not appropriate, the provider informs the enrollee of the authorization decision.
Initial outpatient authorization decisions are communicated verbally to the provider over the phone and are confirmed with a written Notification of Authorization. Subsequent authorization decisions are communicated via mail, unless the situation is urgent and requires immediate communication. Enrollees are notified by the provider of the authorization decisions regarding outpatient treatment.
Authorization decisions are sent to providers, in writing, as a Notification of Authorization. A copy of these decisions will also be sent to the enrollee upon request, or to anyone designated by the enrollee.
Denial of Authorization and Appellate Process
Benefits may be denied for a number of reasons, all of which are defined in the evidence of coverage information provided to the enrollee. Possible denials of authorization are reviewed by individual care managers, care management supervisors, or the Utilization Management Committee (UMC).
All denials for higher levels of care (acute hospitalization, partial hospitalization/day treatment or residential treatment) are reviewed by the supervisor of Inpatient Care Management with the final decision being made by The Holman Group Medical Director. Inpatient care management conferences cases regularly in order to provide peer review/consultation on cases requiring higher levels of care.
Outpatient authorization denials to non-physicians may be made by the Senior Out-Patient Care Manager, who is a licensed psychologist or by the UMC, which is chaired by a licensed psychologist. Note that the UMC reviews outpatient cases that have accumulated 15 or more sessions during the current course of treatment. It may also review, for the purpose of peer consultation, any difficult or challenging cases that a care manager presents to the forum. Outpatient authorization denials to physicians will only be made by a Holman Psychiatrist.
The following are some of the more frequent reasons that denials of authorizations are made:
- The patient meets one or more of the exclusionary criteria mentioned above (both contractual and operational);
- The patient does not meet inclusionary criteria;
- Treatment at the requested level of care is not justified as medically necessary;
- There has been an improvement in functional impairment, severity of illness and risk factors such that the patient does not require treatment at the requested level of care;
- There has been an improvement in functional impairment such that the patient can resume a reasonable level of functioning in most areas of his/her life, maintaining ongoing support through community resources;
- The treatment plan indicated is not appropriate to the treatment of the original problem(s) identified, or is not indicative of solution-focused, brief therapy;
- Following an adequate period of treatment, it does not appear that further treatment will produce significant improvement in the level of functional impairment;
- The patient is repeatedly non-compliant with one or more aspects of the treatment plan, thus impairing the progress and stability of treatment;
- The patient's benefit is exhausted.
Disclosure to Providers and Enrollees of Criteria Used Justifying Treatment Authorization Decisions
All denial decisions are justified to the provider, either verbally or in writing, at the time of the decision. Criteria supporting specific authorization decisions will be disclosed, upon request, to both the enrollee and the provider by a care manager. To inquire about authorization decisions, the enrollee or provider should call or write to the care manager directly requesting justification for the decision.
The materials provided to you are guidelines used by this plan to authorize, modify, or deny care for persons with similar illnesses or conditions. Specific care and treatment may vary depending on individual need and the benefits covered under your contract.
Appeals to Authorization Decisions - Outpatient Care Management
Any provider, patient or subscriber has the right to appeal a care management authorization decision. The request may be made verbally or in writing, although it is strongly suggested that verbal requests be followed by a written request documenting the petitioner's justification for appeal. Depending on the level at which the original decision was made, the following is the hierarchy of review:
- Outpatient Care Manager
- Outpatient Care Management Supervisor
- Utilization Management Committee
- Utilization Management Committee with consultation of staff psychiatrist
Available documentation will be reviewed; additional documentation from the provider may be required.
Any provider, patient or subscriber has the right to appeal a care management authorization decision. The request may be made verbally or in writing, although it is strongly suggested that verbal requests be followed by a written request documenting the petitioner's justification for appeal. Depending on the level at which the original decision was made, the following is the hierarchy of review.
Appeals to Authorization Denials - Higher Levels of Care
The process for appeals review of inpatient/higher levels of care (all levels of care other than Outpatient Expanded and Intensive) will be reviewed by the Supervisor of Critical Care Management and the final decision is made by a Holman psychiatrist. This review is initiated verbally or in writing by the Facility’s attending psychiatrist. This is forwarded to the Critical Care Manager who may require that patient records and documents be submitted for review.
The case in question is submitted to the Supervisor of the Critical Care Management Department along with a request for medical review and subsequently will be forwarded to the Medical Director for final determination. Once the final decision has been made, the Critical Care Manager contacts the Facility’s staff physician in writing.
If a satisfactory decision is not reached, our letter will always document the option of a second appeal by an outside board-certified psychiatrist. Once again, a complete copy of the patient’s record along with a cover letter from the Facility, and the Holman Request for Medical Review will be submitted and reviewed by the second psychiatrist. The decisions made at this level of appeal shall be considered final. The Facility/psychiatrist will be notified both verbally and in writing of this decision.
Complete documentation of the appeals policy and procedure can be made available upon request.
* Clinical Review Guidelines I and II (McKesson Criteria)