DCS Comprehensive Health Plan

Clinical Practice Guidelines and Authorization Guidelines

Policy Statement

This policy provides an overview of DCS Comprehensive Health Plan (DCS CHP) clinical practice guidelines adopted to ensure appropriate utilization of health care resources.

Definitions

Authorization Guidelines (aka Prior Authorization Guidelines): Guidelines based upon clinical practice guidelines and governed by the Medicaid guidelines issued by AHCCCS. Authorization guidelines are used to make authorization determinations for prior authorization, retro authorization, concurrent review and other procedures, medications or services that require authorization.

Clinical Practice Guidelines: Clinical practice guidelines are intended to improve the quality of clinical care by reducing inappropriate variations, producing optimal outcomes for patients, minimizing harm, and promoting cost-effective practices. These guidelines are intended to promote communication among implementers, improve consistency and facilitate user understanding. The guidelines are created by medical professional organizations (many recognized by AHCCCS). The guidelines are designed to be reputable based on the determination of the aggregate evidence quality in support of the recommendation, evaluation of the anticipated balance between benefits and harm and the designation of recommendation strength. An individual policy recommendation in the guideline can be reported as a “strong recommendation,” “recommendation,” “option,” or “no recommendation.” Use of this classification is intended to improve consistency and increase the transparency of the guideline development process facilitate understanding of the clinical practice guidelines, and enhance both the utility and credibility of clinical practice guidelines.

National Committee Quality Assurance (NCQA): is a private, 501 (c)(3) not-for profit organization dedicated to improving health care quality.

Policy

DCS CHP requires its contacted MCO to adopt and disseminate authorization and clinical practice guidelines specific to member needs based upon reliable clinical evidence or a consensus of health care professionals.

Authorization and clinical guidelines applied to the population served by DCS CHP, are adopted in consultation with contracting health care professionals and national practice standards; and involve a thorough review of published clinical practice guidelines, and peer reviewed articles in medical journals published in the United States, when national practice guidelines are not available. Published peer-reviewed medical literature considered include well-designed investigations reproduced by non- affiliated authoritative sources, with measurable results and with positive endorsements of national medical bodies or panels, regarding scientific efficacy and rationale.

The contracted MCO is required to disseminate authorization and clinical practice guidelines, applicable to the population served by DCS CHP, to all service providers and members upon request.

Authorization and clinical practice guidelines that apply to the services for the population served by DCS CHP, provide a basis for consistent decisions for utilization management, member education, coverage of services, and any other areas to which the guidelines apply.

Authorization and clinical practice guidelines are evaluated through a Medical Management (MM) multi-disciplinary committee to determine if the guidelines remain applicable, represent the best practice standards, and reflect current medical standards. The review and adoption of the authorization and clinical practice guidelines as well as the evaluation of efficacy of the guidelines are recorded in the MM Committee meeting minutes.

DCS CHP requires the contracted MCO to comply with the National Committee for Quality Assurance (NCQA) Standards.

Procedure

DCS CHP requires that the contracted MCO develop and adopt authorization and clinical practice guidelines to facilitate quality care, and provide a basis for consistent decisions for utilization management, member and provider education, and coverage of services.

The guidelines are available on the DCS CHP website as well as the contracted MCO website. The guidelines are prepared after a thorough review of the medical literature and consultation with pediatric specialists, as appropriate to the subject matter. DCS CHP documents the review and adoption of the authorization and clinical practice guidelines in the MM Committee minutes, as well as the evaluation of the efficacy of these guidelines.

DCS CHP’s current authorization and clinical practice guidelines are published on the DCS website and outlined in the DCS CHP Mercy Care Provider Manual. In addition, if a prior authorization request is denied based upon an authorization guideline, a copy of that guideline may be included with the denial that is returned to the requesting provider to ensure consistent application of these guidelines in the future.

Monitoring and Reporting

The contracted MCO maintains Clinical Practice Guidelines applicable to the DCS CHP population. DCS CHP evaluates the clinical practice guidelines every two years to determine if the guidelines remain applicable, represent the best practice standards and reflect current medical standards. DCS CHP reports on the review of clinical practice guidelines through the quarterly Medical Management Committee meetings.