Rule 5160-59-03.1 | OhioRISE: utilization management.
(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan will have a utilization management (UM) program with clearly defined structures and processes designed to maximize the effectiveness of the care provided to the member.
(1) The OhioRISE plan has to ensure decisions rendered through the UM program are based on medical necessity.
(2) The UM program has to be based on written policies and procedures that include, at a minimum:
(a) The information sources used to make determinations of medical necessity;
(b) The criteria, based on sound clinical evidence, to make UM decisions and the specific procedures for appropriately applying the criteria;
(c) A specification that written UM criteria will be made available to both contracting and non-contracting providers; and
(d) A description of how the OhioRISE plan will monitor the impact of the UM program to detect and correct potential under-and over-utilization.
(3) The OhioRISE plan's UM program has to ensure and document the following:
(a) An annual review and update of the UM program;
(b) The involvement of a designated senior physician in the UM program;
(c) The use of appropriate qualified licensed health professionals to assess the clinical information used to support UM decisions;
(d) Review and consideration of the child and family centered care plan;
(e) The use of board-certified consultants to assist in making medical necessity determinations, as necessary;
(f) That UM decisions are consistent with clinical practice guidelines as specified in rule 5160-26-05.1 of the Administrative Code. The OhioRISE plan may not impose conditions around the coverage of a medically necessary-covered service unless they are supported by such clinical practice guidelines;
(g) The reason for each denial of a service, based on sound clinical evidence;
(h) That compensation by the OhioRISE plan to individuals or entities that conduct UM activities does not offer incentives to deny, limit, or discontinue medically necessary services to any member; and
(i) Adherence to the Mental Health Parity and Addiction Equity Act (MHPAEA) requirements outlined in 42 CFR Part 438 Subpart K (October 1, 2021).
(B) The OhioRISE plan has to process requests for initial and continuing authorizations of services from their providers and members.
(1) The OhioRISE plan has to have written policies and procedures to process requests. Upon request, the OhioRISE plan's policies and procedures have to be made available for review by the Ohio department of medicaid (ODM).
(2) The OhioRISE plan's written policies and procedures for initial and continuing authorization of services have to also be made available to contracting and non-contracting providers upon request.
(C) The OhioRISE plan has to ensure and document the following occurs when processing requests for initial and continuing authorizations of services:
(1) Consistent application of review criteria for authorization decisions.
(2) Consultation with the requesting provider, when necessary.
(3) Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested has to be made by a health care professional who has appropriate clinical expertise in treating the member's condition or disease.
(4) That a written notice will be sent to the member and the requesting provider of any decision to reduce, suspend, terminate, or deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the member has to meet the requirements of division 5101:6 and rule 5160-26-08.4 of the Administrative Code.
(5) For standard authorization decisions, the OhioRISE plan has to provide notice to the provider and member as expeditiously as the member's health condition requires but no later than ten calendar days following receipt of the request for service. If requested by the member, provider, or the OhioRISE plan, standard authorization decisions may be extended up to fourteen additional calendar days. If requested by the OhioRISE plan, the OhioRISE plan has to submit to ODM for prior-approval, documentation as to how the extension is in the member's interest. If ODM approves the OhioRISE plan's extension request, the OhioRISE plan has to give the member written notice of the reason for the decision to extend the time frame and inform the member of the right to file a grievance if the member disagrees with that decision. The OhioRISE plan has to carry out its determination as expeditiously as the member's health condition requires and no later than the date the extension expires.
(6) If a provider indicates or the OhioRISE plan determines that following the standard authorization timeframe could seriously jeopardize the member's life or health or ability to attain, maintain, or regain maximum function, the OhioRISE plan has to make an expedited authorization decision and provide notice of the authorization decision as expeditiously as the member's health condition requires but no later than forty-eight hours after receipt of the request for service. If requested by the member or OhioRISE plan, expedited authorization decisions may be extended up to fourteen additional calendar days. If requested by the OhioRISE plan, the OhioRISE plan has to submit to ODM for prior-approval, documentation as to how the extension is in the member's interest. If ODM approves the OhioRISE plan's extension request, the OhioRISE plan has to give the member written notice of the reason for the decision to extend the timeframe and inform the member of the right to file a grievance if he or she disagrees with that decision. The OhioRISE plan has to carry out its determination as expeditiously as the member's health condition requires and no later than the date the extension expires.
(D) The OhioRISE plan has to maintain and submit as directed by ODM a record of all authorization requests, including standard and expedited authorization requests and any extensions granted. The OhioRISE plan's records have to include member identifying information, service requested, date initial request received, any extension requests, decision made, date of decision, date of member notice, and basis for denial, if applicable.
Last updated March 25, 2024 at 9:32 AM
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