AZ
| CA | DE | FL | HI
| HIBH | IL | IN
| IABH | MD | MA
| MI | NV
NJ
| NC |
OH
| PA | PABH | TN
| VA | WA | WV | WI
"Attachment
D - Quality Assurance and Utilization Management
A. Quality
of Care
1. In
General...
All plans should
show evidence of a well defined, organized program designed to improve
client care, to monitor over utilization and under utilization, and to
identify and correct aberrant provider behavior…" Arizona Contract,
page D1.
CA
"6.5.9 UTILIZATION
MANAGEMENT...
6.5.9.2 Under
and Over-Utilization
The Contractor
will ensure that the UM program has mechanisms to detect both under and
over-utilization of services." California Contract, page 101.
DE
"12.2 Internal
Quality Assurance and Utilization Management Program
The MCO must
have an internal written quality assurance plan (QAP) that monitors, assures,
and improves the quality of care delivered over a wide range of clinical
and health service delivery areas. The QAP will be reviewed semiannually
by the State or more frequently if necessary. Emphasis should be placed
on, but need not be limited to, clinical areas relating to maternity, pediatric
and adolescent development (including EPSDT), family planning and well-women
care, as well as on key access or other priority issues for Medicaid patients
such as reducing the incidence of sexually transmitted diseases, acquired
immune deficiency syndrome, smoke related illnesses, etc.
Contractors
must satisfy at a minimum: ...
(j) Describe
mechanisms to detect over-utilization and under-utilization of services
by enrollees…" Delaware RFP, pages II.70-II.71.
FL
"27. Quality
Assurance...
g. The
plan's quality assurance program shall have a utilization management component
that includes the following: ...
(2)
The plan must develop procedures for identifying patterns of over-and under
utilization of members and for addressing potential problems identified
as a result of these analyses." Florida Contact, pages 49-51.
HI
"44.020
Quality Assurance Programs...
*
Utilization Review...
The focus of
the utilization management program is to detect underutilization, overutilization,
and inappropriate utilization." Hawaii RFP, pages 59, 62.
HIBH
"• Utilization
Review ...
- The
program should include evaluating medical necessity, the criteria used
and the process used to review and approve the provision of clinical services.
The focus of the UM program is to detect underutilization, overutilization,
and inappropriate utilization." Hawaii Behavioral Health RFP, page
50.
IL
"EXHIBIT B
Utilization
Review/Peer Review
1. The Contractor shall have a utilization review and peer review committee(s) whose purpose will be to review data gathered and the appropriateness and quality of care. The committee(s) shall review and make recommendations for changes when problem areas are identified and report suspected fraud and abuse in the Medical Assistance Program or KidCare to the Department's Office of Inspector General. The committees shall keep minutes of all meetings, the results of each review and any appropriate action taken. At a minimum, these programs must be consistent with certification requirements. The Contractor and Department may further define these programs.
2. The
Contractor shall implement a Utilization Plan, including Peer Review.
Contractor shall provide IDPA with documentation of its Utilization Review
process, including Peer Review. The process shall include: ...
b. Scope
- The program shall have mechanisms to detect under-utilization as well
as over-utilization..." Illinois HMO Contract, Exhibit B, page B-1.
IN
"6.4.7
Quality Improvement and Utilization Review...
In this section
of the proposal, each offeror must also fully describe its program for
guarding against aberrant utilization or misutilization of services.
The offeror must maintain an efficient utilization review program that:
identifies instances of over- and under-utilization; identifies aberrant
provider practice patterns; ensures active participation of a normal review
committee; evaluates efficiency and appropriateness of service delivery;
facilitates program management and long-term quality; and identifies critical
quality of care issues." Indiana RFP, page 6-15.
IABH
"QUALITY ASSURANCE
PROGRAM
(from RFP Section
5.15)...
The QA program
shall incorporate the following requirements: ...
16. Assessing
the access to and evolution of the service delivery system including over-utilization
and under-utilization; special measures shall be developed and implemented
to highlight any problems of access being experienced by Iowa Plan eligible
living in rural areas of the state…" Iowa Behavioral Health Contract,
pages 93-94.
MD
"10.09.64.06...
.06 Access
and Capacity: Benefits and Appointments.
An MCO applicant
shall include in its application the following information or descriptions:
…
L. The
applicant's proposed written utilization management program that specifies,
at a minimum, policies and procedures for...
(6) Utilization
tracking mechanisms and the determination of over-utilization and under-utilization
of health care services…" Maryland COMAR 10.09.64.06.
MA
"Section 2.10
Quality Management...
D. Utilization
Review
The Contractor
shall:
1. Have
a mechanism to detect under... utilization…" Massachusetts Contract,
pages 57-60.
MI
"II-P QUALITY
ASSESSMENT AND PERFORMANCE INPROVEMENT PROGRAM STANDARDS
1. Quality
Assessment and Performance Improvement Program Standards...
The written
plan must also describe how the Contractor will:
*Use measures
to analyze the delivery of services and quality of care, over and under
utilization of services..." Michigan Contract, pages 42-43.
NV
"STANDARD XII:
UTILIZATION REVIEW
A.
WRITTEN PROGRAM DESCRIPTION
The Contractor
has a written utilization management program description which includes,
at a minimum, procedures to evaluate medical necessity, criteria used,
information sources and the process used to review and approve the provision
of medical services.
B. SCOPE
The program
has mechanisms to detect under utilization as well as over utilization."
Nevada Contract, page 70.
NJ
"ARTICLE 15
QUALITY MANAGEMENT
AND UTLIZATION REVIEW...
15.4
The contractor shall establish, implement, and adhere to a written Quality
Management Program (QMP)...
15.6 The
contractor's QMP shall include the following standards: ...
M.
Utilization Review: ...
2. Scope of review to detect under-utilization as well as overutilization…"
New Jersey Contract, pages 76-79.
NC
"7.5 Utilization
Management
The Plan shall
have a written utilization management program that… includes mechanisms
to detect underutilization… The written description shall address procedures
to evaluate medical necessity, criteria used, information sources, and
the process used to review and approve the provision of medical services."
North Carolina Contract, page 16.
OH
"4. Emergency
Department (ED) Diversion...
In order to
receive a provider agreement, the applicant will be required during the
proposal documentation phase to describe its approach to monitor ED use,
promote appropriate utilization, and offer alternative means to access
non-emergency care. Specifically, the MCP will need to address each
of the following in their description of how MCP enrollees will be diverted
from inappropriate- or over-utilization of EDs: …
(b) Describe the MCP's methodology for establishing a threshold for overuse or inappropriate utilization of the ED, identifying over/inappropriate utilizers…" Ohio RFP, pages 19-20.
"5101:3-26-071
MANAGED CARE PLAN: INTERNAL QUALITY ACTIVITIES...
(i) THE
MCP MUST HAVE A WRITTEN DESCRIPTION OF ITS INTERNAL UTILIZATION MANAGEMENT
(UM) SYSTEM WHICH INCLUDES, AT A MINIMUM: ...
(e) MECHANISMS
TO DETECT UNDERUTILIZATION AS WELL AS OVERUTILIZATION..." Ohio RFP,
Appendix E, OAC 5101:2-26-071, pages 1-3.
PA
"M. UTILIZATION
MANAGEMENT...
3. Utilization
Management...
b. Utilization
Management...
Utilization
management practices must also focus on under-utilization of services by
enrollees by providers, by type of services, by eligibility category, etc…"
Pennsylvania RFP, pages 74-77.
PABH
"h. Utilization
Management and Quality Assurance (Part IV, Section E.6)
1)
Describe the process of prior, concurrent, and/or retrospective review
of treatment services to ensure timeliness, appropriateness and medical
necessity. Include:
a)
methods to detect and correct over or under utilization of services;"
Pennsylvania Behavioral Health RFP, pages 24-25.
"6. Utilization
Management and Quality assurance (UM/QA)...
b.
Utilization Management (UM)...
As part
of its utilization management function, the MCO must have processes to
identify over, under, and type of service utilization problems and undertake
corrective action." Pennsylvania Behavioral Health RFP, page 64.
TN
"Guidelines for Internal Quality Monitoring Programs of Managed Care Organizations Contracting with TennCare...
STANDARD XIII:
UTILIZATION REVIEW -
B. Scope
- The program has mechanisms to detect underutilization as well as overutilization…"
Tennessee Contract, pages QCM-2-15.
VA
"L. QUALITY
IMPROVEMENT (QI)...
5. Utilization
Management program Description
The program
must have mechanisms to detect underutilization and/or over-utilization
of care, including, but not limited to, provider profiles." Virginia
Contract, pages 73-75.
WA
"J. ENSURING
APPROPRIATE SERVICE AND COVERAGE [UM 11]
The contractor
must facilitate the delivery of appropriate care and have mechanisms in
place to detect and correct potential under- and overutilization of services.
1. The
contractor must monitor data to detect potential under- and overutilization.
[UM 11.1]
2. The
contractor must routinely analyze all data collected to detect under- and
overutilization. [UM 11.2]" Washington Contract, QIP-2000 Standards,
page 17.
WV
"III-3.
Service Authorization
The MCO must
develop and implement written policies and procedures, reflecting current
standards of medical practice, for processing requests for initial authorization
of services or requests for continuation of services…The plan must have
mechanisms to detect both underutilization and overutilization of services."
West Virginia Contract, Exhibit F, page 13.
"Standard XIII:
Utilization Review...
B. Scope
- The program has mechanisms to detect underutilization as well as overutilization."
West Virginia RFA, Appendix E, page E15.
WI
"Y. QUALITY
IMPROVEMENT (QI)...
3. Monitoring
and Evaluation
a. The QI program
must monitor and evaluate the quality of clinical care and service in institutional
settings, non-institutional settings, and specialty areas (e.g., mental
health and substance abuse) on an ongoing basis. Important aspects of care
(i.e., high volume, high risk, problematic, high cost, high profile care
and services) are identified and prioritized for the development of practice
guidelines. Quality indicators must be used to monitor adherence to guidelines,
and identify patterns of over utilization and under utilization…"
Wisconsin Contract, pages 21, 23.