Utilization Management

The purpose of the utilization management program is to manage the use of health-care resources so members receive the most medically appropriate and cost-effective health care that will improve their medical and behavioral health outcomes. The utilization management department consists of clinical and non-clinical staff members.

Utilization Management Department is responsible to monitor the use of designated services before the services are delivered in order to confirm that they are:

  • Provided at an appropriate level of care and place of service
  • Included in the defined benefits, and are appropriate, timely and cost-effective
  • Accurately documented in order to facilitate accurate and timely reimbursement

 Parkland Community Health Plan physical, behavioral health care services staff receive training to combine clinical skills with service techniques to support the Aetna Better Health of Texas utilization management processes. Our staff receives initial and ongoing training on a regular basis, but no less than annually.

Parkland Community Health Plan utilization management function identifies both over- and under-utilization patterns for inpatient and outpatient services. This review must consider the expected utilization of services regarding the characteristics and health care needs of the member population. Compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any member.

Several procedures require the Participating Provider to notify PCHP of an intent to perform a procedure or provide a particular service or to order DME/supplies/injectables or to refer the Covered Person to a non-Participating Provider. The Prior Authorization List and referral information, along with state-approved forms, is found at Appendix N of this Provider Manual. Once a request for Prior Authorization or referral to a non-Participating Provider is received, PCHP will determine coverage in a timely manner and communicate its coverage decision to the Participating Provider. Failure to obtain required Prior Authorization or referral documentation will result in the denial of claims which should have been the subject of a pre-authorization request.

Utilization review and Prior Authorization/Referral decisions are based on the Covered Person’s Coverage and Benefits documents and any value-added benefits provided by PCHP; the Participating Provider’s contract; and currently accepted medical or health care practices, taking into account any special circumstances for each case. Milliman Care Guidelines®, which are used as the primary screening criteria, are nationally recognized, objective, clinically valid, compatible with established principles of health care, and flexible enough to allow deviations from the norms when justified on a case-by-case basis. PCHP may review the screening criteria and review process in order to make any necessary adjustments.

If a Covered Person or his/her Participating Provider does not agree with a utilization review or prior authorization decision, please contact Member Services regarding an appeal.

PCHP may also use Hayes Technology assessments and information from its claims administrator, research groups, governmental agencies and professional societies as supplemental guidelines in determining the safety, effectiveness and medical necessity of certain services or technologies. Any sources used for supplemental screening are disclosed to the Provider and Covered Person, and a copy of or specific reference to them will be provided upon request. Screening criteria is used to determine only whether to approve the requested service. Flexibility may be utilized when applying screening criteria in determining utilization review decisions for Covered Persons with special health care needs, such as disability, acute condition or life threatening illness.

 

Concurrent Review is the ongoing review of the medical necessity and appropriateness of previously authorized health services, based on the Covered Person’s plan terms, coverage and exclusions. Concurrent Review includes extensions of outpatient services, review of hospitalized Covered Persons and ensuring that discharge planning is underway at the appropriate time.