Physicians and nurses at security health plan use clinical criteria to make coverage decisions based on medical necessity. This is a mandatory training for all providers treating medicare members medicare special needs plan snp providers. Any other material was previously published and remains unchanged. Is there interrater reliability testing and quality. Cabinet for health and family services department for medicaid services. Amdd nonmedicaid services provider manual for sud and adult mental health, effective july 1, 2020. Providers of behavioral health services can use the um guidelines to implement a um program. The pocket card portion uses a flow chart and helpful tips to step through the process of verifying patient status determinations. The utilization management committee chair is a california licensed provider who is charged. Utilization management um is now an integral part of most public and private. Utilization management and population health management plan.
Utilization management plan tenet healthcare corporation. The healthcare management industry is in a constant state of change. Partners operates a prepaid inpatient health plan pihp to manage the medicaid 1915 bc waiver program for its nine county catchment area and also handles utilization management functions for state funded services. Section 7 utilization management allways health partners. Utilization management um and resource management rm. Bcn utilization management providers can contact bcns utilization management department at the tollfree numbers below, unless directed to use another number in this chapter. Tips to help take the hassle out of inpatient utilization. Hirsch, md, facp, chcqm, is vice president of the regulations and education group at accretivepas clinical solutions in chicago. Understanding of the information and reporting requirements contained in the provider operations manual and the california um program. Utilization management sud training behavioral health provider onboarding for substance use disorder benefit expansion december 16, 2020 behavioral health provider onboarding for substance use disorder benefit expansion slides. Updated the manager, behavioralhealth utilization care management position.
In addition to her own books, ccm certification made easy. Utilization management um collaborates with providers to promote and document the. Health partners provider manual utilization management silo of. Utilization management helps ensure that patients have the proper care and the required services without overusing resources. Behavioral healthcare utilization management humana. Bluecross blueshields utilization management um program is a dynamic process whose goal is to facilitate member health management throughout the continuum of care. Molina healthcare michigan utilization management department services. Details are available for the following on the benefit grids page.
Behavioral health utilization management procedure handbook. Take advantage of medical necessity criteria and networkbased provider recommendations at the point of service so your providers and staff can make financially responsible decisions about members care. Our complex case managers cm are rns with specialized training i the management. Interested in utilization management accreditation. Select advanced search to specify dates, collections, or other search criteria. Its a catch 22 of needing mcg training to get a job but need a job to get mcg training. Our program is comprehensive and applies to all eligible members across all product types, age categories, and range of diagnoses.
Urac is widely recognized by nearly every state and the federal government for our health utilization management accreditation program. New hospitalsnf utilization management contact information hospital um contact information authorization contact cheat sheet snf um contact information authorization contact cheat sheet. Provider resource manual section 5 utilization management. Mhs home tricare manuals to15 chap 7 sect 1 medical management utilization management mmum previous next tricare operations manual 6010. Tricare program manuals 2015 edition t2017 tricare operations manual 6010. This training provides a description of the snp model of care. Each tenet hospitals utilization management committee the um committee or committee. All staff involved in utilization management activities possess terminal degrees and licensure in their field. Updated the departmental organization page to include informationregarding the mynavigator program for promedica employees and including overall roles and responsibilities.
The utilization management program manual is a resource for technical assistance to providers to develop and monitor their local um programs and processes. Pinnacol assurances selectnet provider manual was recently updated to be more userfriendly regarding utilization management procedures in compliance with the. Discuss the role of physician advisors in the um process. Provider manual home page utilization management 1 role of the utilization management um department. If you want utilization management with mcg training and. The health plan utilization management um program is designed to ensure members receive access to the right care at the right place and right time. Utilization management and mcg course case management institute. It identifies the special needs population and network, qualifying medical conditions. Medical management mm, utilization management um, and quality management qm chapter 7.
Affiliated providers may discuss a utilization management decision with the security health plan medical director by calling 7152219664 or 18005481224. Feb 04, 2021 banner university health plans b uhp makes health care easier, so your life can be better. Utilization management and mcg course case management. Providers can use this site to access important information related to each of our health plans. Kepro conducts training and technical assistance to assist in improving the internal utilization management structure of provider practices. Each tenet hospital may add to its um plan hospitalspecific utilization management procedures required by the medical staff, its utilization management committee or state regulatory agencies. An overview of the process humana behavioral health uses to determine the best way to resolve patient behavioral health problems. However, if this revision contains a table of contents, you will receive the newrevised information only, and not the entire table of contents. Utilization management um is a process that evaluates the efficiency, appropriateness, and medical necessity of the treatments, services, procedures, and facilities provided to patients on a casebycase basis. This is a mandatory training for all providers treating medicare members. Pcpsspecialists should use the molina healthcare service request form or the michigan healthcare referral form. Rather, it looked at the broad and varied array of organizations that either contract directly with employers to provide utilization management services or, like some hmos and insurers, provide utilization management as part of a larger package of services. Aug 04, 2014 if you have already completed your training requirements through another mechanism, complete and submit the fwa training attestation form. Developing and maintaining ucares case management manual and delegate training.
Utilization management program 2014 molina healthcare medicaidhealthy michigan plan manual page 5 of 16 fax your authorization request, and clinical information if required, to the um department at 8005947404. The problem is, you cant get training and experience with mcg. The purpose of this handbook is to guide providers in the submission of. Utilization management nurses are trained to discuss short and longterm treatment plans, including social and environmental impacts on the healing process. Utilization management um and resource management rm 4. Utilization management program paramount health care.
Reviews are completed 24 hours per day, 7 days per week. The broad objective of the qium program is for patients receiving sud services to receive effective. Delegation of utilization management occurs when ucare contracts with an external organization delegated entity to perform specific utilization management functions. Mvp uses interqual criteria as a guideline for its utilization management decisions for most medical. Among the changes are the roles and functions of utilization management um, which has evolved as a system to evaluate medical necessity and appropriateness of care related to optimal outcomes. The utilization management program manual is a technical assistance document formulated and revised to help the local mental health authorities lmhas develop and monitor their utilization management um programs and processes.
If the patient needs to be in the hospital, emphasize why in the chart. Select retrieve by citation, code of federal regulations and enter year, title and. Kyhealth net electronic pa authorization enduser training. Discuss the impact of diagnosisrelated groups on the healthcare industry. Definitions of utilization management and case management comagine health uses the following urac definitions of utilization management um and case. Nursing beyond the bedside utilization management and. Triage and referral staff members must utilize protocols and guidelines that are uptodate and the staff must be provided appropriate education and training regarding their use. Clinical services is pleased to present our most uptodate care management manual for your use.
The revision date and transmittal number apply to the red italicized material only. As you become familiar with the various chapters, tools and resources please provide feedback to our clinical liasions on improvement opportunities to our services and supports. It identifies the special needs population and network, qualifying medical conditions, care. To bring you the first and currently only course with mcg training outside of an employer. Category 1 utilization managem ent category 2 case management and coordination of care category 3 access and availability category 4 members right s category 5 quality improvem ent category 6 administrative and organizational c apacity guidance on using the technical assistance guide tag.
Utilization management program manual 1 purpose southwestern health resources clinically integrated network herein swhr cin is committed to ensuring the utilization management um program and processes have been developed to maintain andor improve quality, care and service for plan members. Oklahoma state university grand rounds, september 24 2014, utilization management. Describe the role of the um committee in an acute care hospital. Is there ongoing training and education available for caseutilization management and physician advisor teams. This process is run by or on behalf of purchasers of medical services i. Patient status training toolkit for medicare utilization. The program is tailored to meet the individual needs of our members for medical and behavioral health services. Amdd medicaid services provider manual for sud and adult mental health, effective april 1, 2021. The purpose of the utilization management program is to promote fair, impartial and consistent utilization decisions and coordination of care for health plan. Bcbsil commercial and retail hmo utilization management. Medical managementutilization management requirements. Section 5 utilization management overview program objectives.
The care management program is intended to ensure that alaska medicaid1 recipients are provided appropriate medical services in accordance with state and federal regulations, statutes, and policies. Utilization management as a costcontainment strategy cms. Turningpoint offers a comprehensive strategy to managing the unique complexities of surgical procedures and medical device utilization that will. Taking into consideration the various strengths, challenges and complexities inherent in developing. Health partners utilization management decisions are based on. Provider training sessions on utilization management, documentation, and best practices in a variety of formats i.
Provider manual summary of utilization management process. Utilization management case management study guide. Enduser training manual kentucky utilization management project. Oct 07, 2020 changes to the utilization management program description for 2020. The holman group provider manual 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. The committee did not focus on utilization management activities undertaken directly by employers. Technical assistance guide california department of. Ncqa utilization management accreditation helps guarantee that organizations making these decisions are following objective, evidencebased best practices. Utilization management find information, standards and policies for the humana behavioral health utilization management processes. Please seek further information in this manual for authorization requirements for home health, physical, occupational and speech therapy prior authorization information.
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