Care Management/ Utilization Management

1. Care Management/Utilization Management Overview of Care Management/Utilization Management

2. Care Management/Utilization Management • Utilization Management is the means by which Sandhills Center monitors the appropriateness, amount and duration of care by: • Reviewing requests for covered services submitted by member providers • Certifying service requests or recommending other supportive services.

3. Care Management/Utilization Management • Medical Director provides clinical oversight of the Department. • Department is comprised of Master level licensed clinicians who review service request for clinical appropriateness.

4. Care Management/Utilization Management • Clinical Reviewers utilize the State Funded Service Definitions for State funded(IPRS) service requests. • State funded Service Definitions: http://www.ncdhhs.gov/mhddsas/providers/servicedefs/index.htm.

5. Care Management/Utilization Management • Clinical Reviewers utilize the Medicaid Clinical Coverage Policy when reviewing Medicaid covered services. • Clinical Coverage Policy • Enhanced Services: http://www.ncdhhs.gov/dma/mp/8A.pdf • Outpatient Services: http://www.ncdhhs.gov/dma/mp/8C.pdf • Inpatient Services: http://www.ncdhhs.gov/dma/mp/8B.pdf • Residential Services: http://www.ncdhhs.gov/dma/mp/8D2.pdf • Psychiatric Residential Treatment Facility Services(PRTF): http://www.ncdhhs.gov/dma/mp/8D1.pdf • Innovations: http://www.ncdhhs.gov/dma/mp/8P.pdf

6. Care Management/Utilization Management • If the Care Manager is unable to approve the service request a peer review is completed. • Peer Reviews are completed by physicians contracted with the SHC. • Peer Review is intended to give the provider an opportunity to provide additional information regarding medical necessity.

7. Care Management/Utilization Management • Once peer review is completed the physician can recommend approval of the service request or denial of the service request. • If the recommendation is approval, the authorization is immediately approved in the system. • If the recommendation is denial, the member is notified of their appeal rights.

8. Care Management/Utilization Management • Members can appeal the decision to the SHC. This is considered a reconsideration review. • If the decision is overturned, the authorization is immediately approved in the system. • If the decision is upheld, the member is notified of their appeal rights to the State or OAH.

9. Care Management/Utilization Management • If you need assistance with submitting a SAR, you can contact the providerhelpdesk@sandhillscenter.org or you can access Alpha MCS University http://www.alphacm.net/MCSuniversity/ for assistance.

10. Care Management/Utilization Management • Sandhills Center Utilization Management Department toll free number: 1-800-241-1073