DCS Comprehensive Health Plan

Medical Management

Statement/Purpose

This policy outlines the administrative requirements for DCS Comprehensive Health Plan’s (DCS CHP) Medical Management (MM) Program.

Definitions

Medical Management (MM): An integrated process or system that is designed to assure appropriate utilization of health care resources, in the amount and duration necessary to achieve desired health outcomes, across the Continuum of Care (CoC) (from prevention to hospice).

Policy

The DCS Comprehensive Health Plan (DCS CHP) Medical Management (MM) Program assures appropriate utilization of health care resources in the amount and duration necessary to achieve the desired health outcomes for children placed in out-of-home care.

The DCS CHP MM Program includes a written program description with clearly defined structures and processes that consist of the following components:

• Application of appropriate medical necessity criteria;

• Concurrent review;

• Discharge planning;

• Care coordination;

• Disease management; and

• Prior authorization functions.

All components of the MM Program promote integration of care principles and comply with Federal and State regulations and DCS CHP’s contractual requirements with AHCCCS.

DCS CHP evaluates its MM Program at least annually and updates as necessary.

Procedure

Processes/Guidelines

DCS CHP in coordination with its contracted MCO is responsible for MM activities including:

• Utilization data analysis and data management;

• Concurrent Review;

• Discharge Planning;

• Prior Authorization;

• Inter-Rater Reliability;

• Retrospective Review;

• Clinical Practice Guidelines review;

• Review of New Medical Technologies and New Uses of Existing Technologies;

• Care Management and Coordination, including Justice Reach-In, High Needs High Cost coordination, Transition Age Youth coordination and outreach, engagement and re-engagement for behavioral health;

• Disease/Chronic Care Management, and

• Drug Utilization Review.

MM activities and protocols are implemented and monitored through:

• Policies and procedures;

• Reports;

• Practice guidelines;

• Standards for authorization decisions;

• Documentation resulting from clinical reviews [e.g. notes related to concurrent review, retrospective review, and Prior Authorization (PA)];

• MM Committee meeting minutes including analyses, conclusions, and actions required with completion dates;

• Corrective Action Plans (CAPs) resulting from the evaluation of any component of the MM program such as Inter-Rater-Reliability, and

• Other information and data deemed appropriate to support changes made to the scope of the MM Plan.

Data Utilization Process:

DCS CHP maintains integrated systems and processes to support Utilization/Medical Management (MM), and Quality Management and Program Improvement (QM/PI) activities, including the collection, analysis and dissemination of data.

Data related to providers, members and claims is captured by the contracted MCO and provided to DCS CHP for analysis and implementation of the MM and QM/PI Programs. The MM program utilizes data to:

• Review and evaluate the results of MM activities;

• Identify opportunities for improved care;

• Monitor and evaluate utilization of services for under and over utilization patterns and/or potential abuse or misuse by providers and members;

• Monitor performance measures; and

• Prepare statistical reports for AHCCCS and other constituents.

Participation and Reporting

DCS CHP works in conjunction with its contracted MCO to complete MM activities under the direction of the DCS CHP Chief Medical Officer (CMO).

MM data is reported to the MM Committee and Pharmacy & Therapeutics Committee for further review and collaboration with the Quality Management Process Improvement (QM/PI) Committee, and other functional areas of DCS CHP, to ensure regular analysis of trends and identification and implementation of process improvements.

DCS CHP and its contracted MCO prepares an annual MM Plan outlining strategies and activities impacting physical and behavioral service delivery for children placed in out-of-home care. Annual evaluations of the effectiveness of the previous year’s strategies and activities are also prepared.