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					UNIVERSITY OF ILLINOIS AT CHICAGO PHYSICIAN GROUP


         UTILIZATION MANAGEMENT PLAN


                      2004
Purpose

The overall purpose of the Utilization Management (UM) Plan for University of Illinois
at Chicago Physician Group (UICPG) is to describe the utilization management program
and define the role and responsibilities of the Medical Management Committee. The Plan
defines the utilization management processes, delegated and non-delegated activities, and
the evaluation of the utilization management program. This formal written plan, to which
UICPG is accountable, is designed to meet the risk contracts (HMO) requirements.

Scope

The Utilization Management Program is designed to monitor, evaluate, and manage the
cost and quality of healthcare services delivered to all members of UICPG. Whether
delegated or non-delegated, this program includes, but is not limited to, inpatient and
outpatient services as follows: referral, diagnostic testing, therapies, behavioral health,
acute care, skilled nursing services, rehabilitation services, ambulatory surgery services,
home health care. The Plan includes, but is not limited to a description of the processes
for accomplishing the following:
 pre-certification,
 initial, concurrent and/or retrospective review,
 referrals,
 denials/appeals, including expedited appeals,
 complaints, corrective action,
 case management/discharge planning,
 triage and screening for behavioral health cases,
 diagnoses/procedures/services/physicians that do not require review based upon
    historical UM data.
The plan also incorporates ambulatory/services, out-of-plan and emergency care.

Objectives

To assure the utilization of medical services is in accordance with medical necessity, the
appropriate level of care and access to care.

To monitor and review the appropriateness and timeliness of the UM determinations by
licensed health care professionals.

To assure decisions are based upon relevant clinical information and are within the
guidelines of the standard of care specific to the member’s needs (including out-of
network determinations).

To assure the Utilization Management Program meets the requirements for contracted
managed care plans, state and federal regulatory and accreditation agencies, i.e. NCQA,
URAC, and Department of Labor Guidelines.


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To provide education and feedback to physicians regarding practice patterns and
comparative data.

To monitor and review the following processes: referrals, precertification of services and
procedures, inpatient initial, concurrent and retrospective hospital review, case
management, discharge planning, denials/appeals, complaints, corrective action, and
triage and screening for behavioral health cases.

Goals

Goals are developed annually after the review of the following:
       Analysis of requirements of the HMO’s
       Analysis of utilization of services and determination of over utilization and/or
       under utilization
       Provider and member feedback and input
       Changes in regulatory and accreditation requirements

Goals for 2004

Maintain Bed Days per Thousand (BD/K) at or below pre-established targets i.e.
BlueCross/BlueSheild HMOs network average
 Hospital days will meet acceptable medical criteria
 The Medical Management Committee on a monthly basis will review avoidable
   hospital days
 Avoidable days data will be compiled, trended by PCP and evaluated on a quarterly
   basis

Referrals should be issued to providers within the UICPG network
 Medical Director will review and approve all out of network referrals
 Referral patterns of primary care physicians will be reviewed and education provided
   on an as needed basis

Pharmacy Formulary Compliance
 Increase utilization of HMO I/Blue Advantage drug formulary
 Increase utilization of generic drugs




Responsibility/Authority

The Board of Trustees of the University of Illinois is responsible for ensuring that quality
care and services are provided to contracted, capitated managed care members at the
University of Illinois Medical Center at Chicago. The Managed Care Committee (MCC)

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has the delegated responsibility and authority from the Board of Trustees of University of
Illinois for assuring that quality care and services are provided to contracted capitated
managed care members. In order to accomplish the program goals a Medical
Management Committee (MMC) is established and charged by the MCC with this roll.

Plan Approval

The Medical Director, UICPG Director of Business Development and the Apex Director
of Utilization Management will review the existing UM Plan, discuss any issues with the
UM Plan from the prior year, discuss any new ideas for the UM Program, and revise the
UM Plan. This will be done an annual basis. After which, the UM Plan, with
recommended changes will be forwarded to the Medical Management Committee (MMC)
for final approval. The Medical Director as Chairmen of the Medical Management
Committee will sign the signature page affirming the MMC has approved the Plan and
the revised Plan will be submitted to the HMOs as required by contract.

Standards and Criteria

All covered benefits will be provided to members consistent with recognized professional
standards. Nationally recognized criteria (Milliman & Robertson) will be followed
during medical review along with input from the medical director, primary care
physician, and board certified specialists.

Annually, the Medical Management Committee will update, review and approve the
medical criteria of Milliman & Robertson. This criteria will be used in medical necessity
review and LOS determinations.

Contracted specialists will follow the medical, quality, and utilization policies of UICPG.
These include but are not limited to adherence to health plan referral and precertification
requirement, adequate access, equal treatment, treatment consistent with recognized
standards, full disclosure of health care options, and informing member of follow up care.

Confidentiality Statement/Protected Health Information

Confidentiality of the members’ medical records and data will be maintained in
compliance with contracted managed care plans and HIPAA requirements as defined in
the attached policy and procedures.



Delegation and Oversight

If UICPG sub-delegates any UM Function to another entity (e.g. contract management
firm (CMF), hospital UR department, Behavioral Health/Mental Health facility or group),
that entity will be named and specific contact information documented in this UM Plan.

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The sub-delegated entity will be responsible for all UM activities for which it is
contracted. The Medical Management Committee will monitor and evaluate the activities
of the entity and document this in the monthly Medical Management Committee minutes.

When the UICPG initiates sub-delegation the HMOs will be notified within 30 days.
Prior to the sub-delegation, UICPG will determine the entity’s capacity to perform the
delegated activities. The entity’s UM Plan will be available to HMO’s upon request. The
Medical Management Committee will review the sub-delegated entity’s UM Plan and
Program annually to assure compliance with HMO requirements and will document this
in the Medical Management Committee minutes. The responsibilities and delegated
activities of the entity will be included in the UM Plan. The sub-delegated entity is
responsible for all of UICPG UM activity for which it is contracted. The sub-delegates
must meet the HMO standards set forth in the HMO UM Plan.                 The Medical
Management Committee evaluates and provides oversight of the entity’s performance
including submissions required by the HMOs.

UICPG has sub-delegated the operations of the utilization management activities to
Apex HealthCare 440 Quadrangle Drive #B Bolingbrook, Illinois 60440.

Program Organization-Apex HealthCare

Apex HealthCare’s Director of UM, who reports for these activities to the UICPG
Medical Director, executes the delegated day-to-day responsibility for the utilization
management function. Apex staff includes administrative staff and registered nurses who
perform all aspects of utilization management for UICPG in accordance with specific
policy and procedures that meet the requirements, standards and time frames outlined in
the UICPG UM Plan. Staffing to support the utilization management function for the
contract is based upon membership. The utilization activities include but are not limited
to the pre-service process, inpatient and outpatient review, case management, discharge
planning and quality of care review. The Case Manager is a licensed professional nurse in
Illinois, whose responsibilities include review of daily utilization review activities. The
Case Manager’s principal duties include but are not limited to:

       Review activities including initial, concurrent and retro-review for acute inpatient
        hospitalizations, acute rehabilitation, SNF and home health care (Description of
        inpatient review process see pages 20-23)
       Proficient in the use of medical terminology and nationally recognized medical
        criteria
       Communicates and discusses cases with the Medical Director, Physician Advisor,
        and the Primary Care Physicians as the need arises
       Serves as the primary UM contact for the HMOs
       Coordinates with the PCP the authorizations of home health care, durable medical
        equipment, and transfer to alternative levels of care.
       Coordinates appropriate discharge planning with hospitals and skilled nursing
        facilities

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       Coordinates the transfer of out of network admissions to hospitals in network

Apex uses a telephonic and on site review process to obtain clinical information from
facility case managers/discharge planners. Staff that performs pre-service referrals work
directly with the physician to assure that all clinical information is obtained, referrals are
processed correctly, and nationally recognized criteria is appropriately applied. Apex’s
Case Managers report to the Director of Utilization Management who reports to UICPG
Medical Director and Director of Business Development. On occasion, in order to
maintain operational efficiency it may be necessary and appropriate to have some QI
activities conducted by the affiliated hospital, and/or providers with which UICPG is
contracted.

Staff Education, Training and performance monitoring of clinical and non-clinical
utilization review staff are provided in accordance with the attached policy and procedure
(Apex UM 1).

The specific responsibilities delegated to Apex are outlined in the contract between the
two entities. Apex will provide monthly reports to UICPG Medical Management
Committee. The monitoring and evaluation will be through the review of the utilization
management functions and statistics and/or other elements identified in UICPG UM Plan.
The review and evaluation will be documented in the monthly Medical Management
Committee minutes, which are forwarded to UIC Managed Care Committee. If
deficiencies are identified in meeting the performance standards outlined in the contract
between Apex and UICPG, the Managed Care Committee of UIC will require
implementation of a corrective action plan until performance standards are met. Failure
to address performance deficiencies will result in further action up to and including
termination of the contract. Annually, UIC Managed Care Committee evaluates the
performance of the delegated entity.

UM reviews are conducted on-site and telephonically. The Apex Case Manager conducts
on-site reviews at the University of Illinois Medical Center at Chicago. The UICPG
documented process includes the following, which is in accordance with the attached
policy and procedure (UM 007):
a) guidelines for identification of Apex staff at the facility (in accordance with facility
    policy);
b) a process for scheduling the on-site review in advance (unless otherwise agreed
    upon); and
c) a process for ensuring that Apex staff follows facility rules.


UTILIZATION MANAGEMENT (MEDICAL MANAGEMENT) COMMITTEE

Authority




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The Medical Management Committee (MMC) is a standing committee, which functions
as a Utilization Management Committee and reports to the Managed Care Committee of
University of Illinois at Chicago. The Managed Care Committee holds delegated
authority from the Board of Trustees, who have the ultimate accountability for the
Utilization Management Plan.

Structure

The MMC committee is made up of the Medical Director, Primary Care Physician, and
Specialist representation. The physician members should be actively practicing and
currently licensed in the state of Illinois. Other members include the Director of Business
Development, Director of UM (Apex), support staff, and ancillary personnel. Physicians
contracted with the physician group are voting members. A quorum is present with
minimum of three voting members present. Physician members serve a term of two years
and may succeed themselves. Vacancies will be filled through an appointment process.

The medical Director is the Chairman and is responsible for:

   Appointment of members
   Establishing the agenda
   Signing the minutes
   Prioritization of issues addressed

The committee membership list includes each individual’s degree and specialty.

Functions

Committee, as a whole or as it delegates, is to provide direction and monitor the
utilization of health resources provided. Through the collection and evaluation of data,
the Committee will take reasonable steps to manage the utilization of medical services
(ambulatory and inpatient) according to medical necessity and the appropriate level of
care. This includes, but is not limited to:

       Meets monthly to review and discuss UM activities. Documentation includes
        date, members present (professional degrees noted), minutes signed by the Chair
        within five weeks of the date of the last meeting

       Review and discussion of utilization statistics to include:

        Monthly:          Any potential long-term inpatient cases, readmissions, or any cases
                          requiring coordination of care will be discussed and documented in
                          the monthly minutes.
                          Raw data-admits/1,000, days/1,000, ALOS, referral statistics and
                          denial/appeals will be discussed and documented in the monthly
                          minutes.

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                      Denial discussion must include a summary of the category of
                      denials (When appropriate Behavioral Health and non-
                      Behavioral Health: medical necessity, out-of-network and
                      benefit), number in each category, timeframes compliance, and
                      resolution.
        Quarterly:    Analysis of data, when appropriate including behavioral health, to
                      identify trends and patterns as well as reviews and studies of those
                      identified trends and patterns.
                      Discussion of referral statistics, including behavioral health
                      referrals, to include comparison, analysis, discussion, and trending
                      of referrals will be documented in the minutes. If no trends are
                      identified during analysis, this will be documented.
                      Discussion of all complaints (including BH) received by the group.
                      These may be discussed in summary format using categories of
                      complaints; such as: access, PCP issues, etc. A monthly log of
                      these complaints must be maintained.             Resolution of the
                      complaints and the timeframe must be documented on the log
                      or in the minutes.
        Semi-annually:Identification, analysis and development of interventions for
                      improvement relating to the utilization statistics studies, including
                      behavioral health when appropriate, on trends, patterns and/or
                      physician practice patterns. Four of the following statistics will be
                      tracked including one for behavioral health: inpatient days/1000,
                      admits or discharges/1000, behavioral health days/1000, average
                      length of stay, rates for types of procedures. Potential under-or
                      over-utilization will be noted, when identified. Analysis will
                      include comparison of past quarters. Recommendations for
                      improvement will be documented, if needed. If no interventions
                      are needed, this will be documented.
        Annually:     evaluation of effectiveness of interventions relating to the
                      utilization statistics studies, including behavioral health, on trends,
                      patterns and/or physician practice patterns.

       Referral statistics will be reviewed, analyzed, and discussed monthly. The
        specific types of referrals to be logged and monitored will be identified on an
        annual basis. Logs are maintained on a monthly basis. If there are no referrals for
        the month, this will be documented in both the minutes and on the log. The
        determination will be based upon referrals, which are considered high risk, high
        volume, and/or high cost. The logs will be available to managed care plans upon
        request. The logs include at a minimum: Dermatology, Urology, Out-of Plan and
        Behavioral Health referrals.

       Denial/Appeal process is reviewed monthly to insure denials are managed
        appropriately and based upon written nationally recognized medical criteria.
        Corrective action and follow-up is documented as needed. A log will be

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        maintained and reviewed monthly. If no denials are logged for the month, this is
        to be noted in the minutes and on the log. Denial/appeal logs will be submitted
        to the HMO by the 10th day of each month. Quarterly review and discussion
        of HMO review of UICPG’s denial files, any non-compliance and corrective
        action, if required.

       Member Complaint Process: Complaints received from patients, patient’s
        family/guardian, payer, physician, or facility staff will be documented on a
        complaint form. An investigation is conducted and resolution determined. The
        complaints must be resolved within 30 days. Payers/patients are notified as
        appropriate and indicated. All complaints received by UICPG will be reviewed
        and discussed monthly at the Center Medical Director Committee Meeting and
        include:
         Complaints received at UICPG
         Quality of care complaints received by UICPG or forwarded by the HMO
         HMO Administrative complaints
         HMO IRIS member complaints (annually)
         Complaint Log maintained monthly for all complaints
        If there are no complaints for the month, that will be documented.

       Semi-annual review of staff adherence to medical criteria (Inter-rater Reliability
        Results). Physician Advisors, Medical Director and UM Staff will be included in
        this documentation. The results of the review will be discussed at the Medical
        Management Committee.

       Semi-annual review of staff adherence to decision making time frames and inter-
        rater reliability testing for criteria utilization. Review of staff adherence to all
        time frames established for UM decisions including precertification, concurrent
        review, member complaints, denials and appeals, retrospective review, and
        referral case review. A summary of the results by reviewer will be included the
        minutes. Corrective action plans will be discussed and documented in the MMC
        minutes as the need arises.

       Contract Management Firms (CMF) over sight as appropriate: Monthly and
        quarterly review and discussion of CMF oversight analysis of any submissions,
        i.e. data, reports and logs. Quarterly reporting will include reference to
        telephone statistics and compliance with HMO standards.

       UM Plan annual review: The annual review and evaluation of the UM Program,
        which includes Behavioral Health functions, UM related policies and procedures
        will be documented. The review will include any new UM Programs initiated
        during the year, utilization statistics, and plans for the upcoming year. The annual
        review will be documented in the MMC meeting minutes.

       UM program and progress in meeting determined goals will be evaluated

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        annually. All goals identified for the year will be discussed. Interventions
        implemented, successful outcomes, and further opportunities for improvement
        will be discussed and documented in the MMC minutes.

       Medical criteria including behavioral health selected, reviewed and updated
        annually. The annual review and approval will be documented in the MMC
        meeting minutes.

       PCP survey of satisfaction with the UM process that the HMO performs is
        reviewed annually and documented in the MMC meeting minutes.

Meeting Frequency

The Committee will meet at least once a month; the Medical Director on an as-needed
basis may call meetings more frequently.

Minutes Documentation

Minutes will be kept of each meeting documenting:
    Members present, including professional degrees
    Chairperson
    Review, acceptance/modifications to minutes from prior meeting.
    Documentation of Utilization Management statistics discussion to include:

                         Referral statistics-to include Dermatology, Urology, and Out of
                          plan Referral Logs raw data review (monthly)
                         Analysis, review, interventions and evaluation of interventions of
                          Referrals (quarterly)
                         Complaints and Log monthly and quarterly
                         Evaluation of performance of studies on trends/patterns (quarterly)
                         Interventions (semi-annually)
                         Evaluations of Interventions (annually)
                         All reviews and actions taken by the committee
                         Denial/Appeal Logs (monthly)
                         Behavioral Health monthly reports (raw data review) to include-
                          Referral Log, Denial/Appeal Log, and Complaints received.

Through the information gathered from the collection and discussion of statistical
utilization data, the Committee will take necessary and reasonable steps to control and
prevent both over utilization and under utilization of medical services.
The minutes will be reviewed and signed by the Medical Director within five weeks from
the date of the meeting. Copies will be distributed to Managed Care Organizations as
contractually required. These documents will be maintained on file.



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Reports and Surveys

UICPG will distribute the following to all their PCPs: reports, surveys, UM Criteria, the
UM Plan, UM statistical reports specific to UICPG and other materials. This information
is also available upon request.




UTILIZATION MANAGEMENT PROGRAM

Goals



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To monitor and review the appropriateness and timeliness of the Utilization Management
determinations by the licensed health care professionals.

To assure decisions are based upon relevant clinical information and are within the
guidelines of the standard of care specific to the patients’ needs.

To assure the Utilization Management Program meets the requirements of contracted
managed care plans, state and federal regulatory and accreditation agencies, i.e. NCQA &
URAC and Department of Labor Guidelines.

Objectives

The program will employ three basic review processes: prospective, concurrent and/or
retrospective review.    The review processes will incorporate referral management,
precertification, admission and in-patient case management, discharge planning,
ambulatory surgery/services, behavioral health, out-of-plan and emergency care.

The approval/denial process will include input of appropriate Board Certified specialists
as deemed necessary by the Medical Director. The Medical Management Committee will
review all denial/appeals. Written notification will be provided to the patient (copy to
physician) with the relevant clinical information supporting the decision and information
regarding the appeal process as indicated by the policies of the appropriate insurance
plan.

UM policy changes will be submitted in writing to the HMOs within 30 days of
implementation of the change.

Medical Management Organization and Responsibilities

All physicians practicing/participating within UICPG will be currently licensed to
practice medicine in Illinois, and will be currently credentialed by BCBSI as well as the
other managed care plans affiliated with the Group. Annually, a list including the names
of the Medical Director and all Physician Advisors (the Medical Director acts as the
Physician Advisor) will be submitted to BCBSI. The HMO will verify physician licenses
through the HMO credentialing department.

Appropriate staff will be maintained to perform UM functions with the minimum staffing
requirements as follows:


Medical Director

The Medical Director is a licensed physician of the state of Illinois, who under the
authority of the MCC, develops and assesses the clinical functions of the medical staff.
The Medical Director’s responsibilities include planning, organizing, selecting,


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monitoring, and evaluating the medical staff to assure the delivery of quality medical
services to patients. (see Job Description Attachment 2)

The Medical Director serves as an internal physician advisor for the medical staff.
Responsibilities include, but are not limited to:
    Supervising all UM decision-making
    Approving the final UM Plan
    Monitoring the implementation of the Medical Group UM Plan
    Educating the medical staff regarding the UM policies and procedures
    Making final decision for utilization issues including denials
    Overseeing the analysis of trends, profiling and long term planning
    Oversight of Contract Management Firm when appropriate
    Ensuring the proper functioning of the Medical Management Committee
    Monitoring and evaluating the health care of UICPG’s members
    Overseeing the behavioral health care of UICPG’s members

Physician Advisor (P.A.)

Is a licensed physician most directly involved with individual case review. The Medical
Director of UICPG acts as the Physician Advisor. This physician reviews all cases that
do not meet the medical necessity guidelines and length of stay (LOS) determinations.

Specialists

Board certified specialists, including a licensed clinical psychologist, are available to
assist in medical necessity determination. This list is updated annually and submitted to
the managed care organizations. See Attachment 8

Director UM

Is a licensed professional nurse in Illinois, who is proficient in the use of medical
terminology and nationally recognized medical criteria and is able to communicate
accurately with the Medical Director, and Primary Care Physicians. The Director’s
responsibilities include oversight of the day-to-day operations of the Utilization
Management department. This includes direct supervision of Case Management Nurses,
Behavioral Health Coordinator, and support staff. Works in collaboration with the
Medical Director to organize the Medical Management Committee. Assures sufficient
staff is available to perform necessary reviews.

Case Manager
Is a health professional and possesses an active professional license or certification,
whose responsibilities include review of daily utilization review activities. Professional
staff licensure will be verified every three years, at a minimum. The Case Manager’s
principal duties include but are not limited to:


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       Review activities including initial, concurrent and retro-review for acute inpatient
        hospitalizations, acute rehabilitation, SNF and home health care (Description of
        inpatient review process see pages 20-23)
       Proficient in the use of medical terminology and nationally recognized medical
        criteria
       Communicates and discusses cases with the Medical Director, Physician Advisor,
        and the Primary Care Physicians as the need arises
       Serves as the primary UM contact for the HMOs
       Coordinates with the PCP the authorizations of home health care, durable medical
        equipment, and transfer to alternative levels of care.
       Coordinates appropriate discharge planning with hospitals and skilled nursing
        facilities
       Coordinates the transfer of out of network admissions to hospitals in network

Behavioral Health (BH) Utilization Management (UM) Coordinator

Is a mastered prepared, licensed mental health professional and is responsible for the day-
to-day utilization review activities of members in need of behavioral health services. The
BH UM Coordinator is proficient in the use of medical and mental health terminology
and nationally recognized medical and mental health criteria and is able to communicate
accurately with the Medical Director and Primary Care Physicians (PCPs). The BH UM
Coordinator serves as the primary BH UM contact for the HMO.

Staff Education and Training

Orientation, training, and ongoing performance monitoring of clinical and non-clinical
utilization review staff are provided in accordance with the attached policy and
procedure. (see Apex UM 1)

Affirmation Statement

The Affirmation Statement, which is distributed to all staff involved with UM decisions,
affirms that:
 UM decisions are based on medical necessity, which includes appropriateness of
    care and services and existence of available benefits;
 The organization does not specifically reward health plan staff, providers or
    other individuals for issuing denials of coverage, care or service;
 Incentive programs are not utilized to encourage decisions that result in under-
    utilization.

UICPG also affirms that there is no conflict of interest between the medical group and it’s
UM decision-makers. This statement will be added to the member Welcome Letter, the
physician newsletter and/or posted in the offices. See attachment 4 memo.



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Clinical Criteria Selection of UM Decisions

Milliman & Robertson, Inc. Healthcare Management Guidelines including In-patient and
Surgical Care, Pediatric Health Status Improvement and Management Primary Care,
Recovery Facility and Home Care and Mental Health Optimal Recovery Guidelines will
be utilized for review. Criteria will be reviewed and updated annually.

Utilization review criteria will be evaluated and approved by the Medical Management
Committee at least on an annual basis and documented in the meeting minutes with the
effective date of implementation. The medical criteria will be evaluated for compliance
relative to current nationally accepted standards of care. Input from at least one Board
Certified specialist from each of the medical group’s several high volume specialty areas
will be included. A Behavioral Health specialist will be available as needed to assist in
making Behavioral Health determinations and approving criteria. Annually, Primary
Care Physicians as well as consulting specialists will be notified in writing of adopted
criteria and any additional guidelines, copies will be made available to them upon
request. See Attachment 9.

If situations occur when nationally recognized criteria are not available, UICPG may
adopt additional objective criteria, clinical pathways, and/or guidelines. They must
be reviewed by the MMC and chosen based upon scientific medical evidence.
Discussion of how the additional criteria, clinical pathways, and/or guidelines were
chosen must be identified in the UM Plan as part of the criteria approval process.
The criteria are reviewed and approved annually, including any procedures for their use,
through the Medical Management Committee. The development process of the criteria
must include input from an appropriate specialist. Annually, the criteria and procedure(s)
will be submitted to the HMO with the UM Plan. Review and approval of the criteria
will be documented in the Medical Management Committee minutes.

Application of Criteria

To support UM decision making, the Case Manager will gather and document relevant
clinical information including information from the attending physician. The review
sheet will include where clinical information was obtained, i.e. PCP, lab, and medical
record. Relevant clinical information may include but is not limited to lab tests,
physician’s progress notes, x-ray reports, and individual patient circumstances as listed
below:
     Age
     Comorbidities
     Complications
     Progress of treatment
     Psychosocial situation
     Home environment, when applicable



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       Benefit coverage for services needed as outlined in the Scope of Benefits and /or
        available through inquiries made to HMO Customer Service (benefit
        determination)

The Case Manager also considers characteristics of the local delivery system that are
available for the patient including:

       Availability of skilled nursing facilities or home care in the service area to support
        the patient after hospital discharge.
       Coverage of benefits for skilled nursing facilities or home care when needed
       Ability of local hospital(s) to provide all recommended services within the
        estimated length of stay

Cases that do not meet the nationally recognized medical criteria (Milliman & Robertson)
are:

       Reviewed by the Medical Director/P.A., who will make a determination taking
        into account the individual patient’s circumstances including age, comorbidities
        and psychosocial needs. The review should be completed within 24 hours of
        notification of the admission.

       Prior approval from the Health Plan is necessary, if a denial of inpatient benefits is
        to be issued.

       If a denial is issued, the member and practitioner are to be notified of the decision
        in writing or electronically, within 24 hours of receipt of request.

       Written 24-hour notice is given to the PCP, consulting physician, and patient prior
        to discontinuing inpatient benefits.

       If inpatient benefits are denied, related physician costs are also denied.

Any diagnoses not listed in Milliman & Robertson’s Guidelines, will be reviewed by the
Medical Director/P.A. for determination of medical necessity and anticipated LOS.

Monitoring Quality of Program

Review of the Utilization Management staff is conducted semi-annually. Case Managers,
BH UM Coordinator, Referral Coordinators, and the Medical Director and Physician
Reviewers (see attachment 5) are evaluated semi-annually for Inter-rater Reliability. Case
Managers and Referral Coordinators are evaluated for Adherence to Timeframes semi-
annually. The inter-rater reliability monitor assesses consistency in the application of
nationally recognized medical criteria. The timeframes monitor determines the level of
compliance with adherence to the established time frames for making UM decisions
including urgent and non-urgent pre-service review, initial review, concurrent review,

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member complaints, denials and appeals, post-service/retro-spective review, and referral
case review.  The results of the audits are reported to the Medical Management
Committee.

Problems or complaints regarding the Utilization Management Program will be reported
to the Medical Management Committee for review and investigation. The Medical
Director and the Medical Management Committee are responsible for corrective action
plans and monitoring of identified issues.

Physician satisfaction surveys relative to the Utilization Management process will be
conducted annually by the HMOs.

Access to UM Staff

The following communications services for UICPG practitioners and members is
available:
a) at least eight hours a day, during normal business hours, staff will be available for
   inbound calls regarding UM issues at 312-996-4374;
b) UM staff will have the ability to receive inbound after business hours communication
   regarding UM issues i.e. an answering service linked to the above telephone number;
c) UM staff have outbound communication available regarding UM inquiries during
   normal business hours;
d) calls will be returned within one business day of receipt of communication;
e) staff will identify themselves by name, title and organization name when initiating or
   returning calls;
f) staff will accept collect calls regarding UM issues; and
g) callers will have access to UM staff for questions; and
h) inbound and outbound communication process and the method for receiving after
   hours communication is documented in the UM Plan.

Practitioners are notified of access to UM staff for questions and the availability of a toll
free number via their newsletter and physician training. Members are notified of the UM
access via their Welcome Letter. See Attachment 6




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REFERRAL PROCESS

Purpose: The referral process is a mechanism utilized to control utilization and cost in
the managed care environment. Screening specialist visits for medical appropriateness
and insuring the utilization of a contracted specialist network accomplish this.

Goal: To assure referrals to specialists and ancillary providers are directed within the
contracted network, are medially appropriate, and are compliant with the five day
turnaround timeframe. (See below and Page 18)

Routine Referrals

Initiation of the referral process requires a written request for all services referred by the
Primary Care Physician (PCP) including labs, diagnostic testing, therapies and specialist
evaluation or other consultation services. Members in need of Behavioral Health services
obtain a referral from their PCP (see Behavioral Health Addendum). Referrals from in
plan provider to in plan provider within the Medical Group require approval from
UICPG. A referral log is maintained. Upon the member’s request, a copy of the referral
via fax or mail will be provided to the member.
The PCP completes the referral request form (attachment 7). The information must
include:
     Date of request, patient name, DOB, insurance, sex diagnosis, relevant clinical
         and social factors related to this referral request, type of referral, requested
         service, provider, number of visits or extent of treatment and facility if applicable.
     Signature of Primary Care Physician.
     Referral requests, which require pre-authorization, (see policy & procedure
         UICPG UM-001) should be faxed directly to Apex UM Department.
     Referral requests, are date stamped when received by Apex and member’s
         eligibility and benefits are verified.
     Global referrals are issued for diagnoses requiring extended care i.e. dialysis,
         fracture care, obstetrical and chemotherapy.
     Non-urgent referrals (i.e. therapies, DME, diagnostic testing, and lab)
         determinations (approval/denial) will be made within 5 calendar days of receipt of
         request, including the collection of all necessary information. If this type of non-
         urgent referral is denied, the PCP and member will be notified in writing or
         electronically within (5) calendar days of receipt of the request.
     Referral decisions for specialist referrals will be rendered, and the member
         and practitioner(s) notified of the decision, within five (5) calendar days of
         receipt of the request, including any requests for additional information.
     Denied specialist referrals will be communicated to the PCP and member in
         writing or electronically within five (5) calendar days of receipt of the
         request.



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       The Medical Director reviews the out-of-network referrals considering appropriate
        nationally recognized criteria/guidelines and approves, modifies or denies the
        referral request.
       Referral requests may be returned to the PCP requesting additional information
        (medical necessity) to support the request. Documentation of relevant clinical
        information and sources (such as medical record, lab results, information from the
        PCP) and date received.
       The PCP can telephone the Medical Director to discuss the request as necessary.
       Denied referrals will include the date additional information was requested in
        order to make the denial decision, and the date the information was received.

All written referrals must include the following elements:
 documentation of the date received by Apex;
 documentation of the member name and patient identifier number;
 documentation of the reason for referral;
 documentation of the number of visits or extent of treatment;
 referral form must be signed and dated by PCP/PCP office; and
 referral must include a statement that referral does not authorize benefits for non-
    covered services.

Additional requirements related to referrals include:
 maintenance of a referral log by Apex;
 providing the member with a copy of the referral (UICPG or PCP will mail or fax a
   copy to the member, if requested by the member.)

Referrals, including but not limited to, therapies, diagnostics, DME, and specialists, will
be monitored by Apex for quality of care, appropriate utilization, and compliance with
UM decision making time frames, including the five working day turnaround timeframe
for specialist referrals.

Referral Cases Closed

When routine specialist referral requests are returned to the PCP requesting additional
information (medical necessity) to support the request and adequate information to
support the medical necessity of the request for service is NOT received within the five
(5) day timeframe, the case will be closed. A Referral Closure Letter (attached) will be
sent to the member and a copy to the Primary Care Physician. The Closed Cases are
neither approved nor denied. Upon receipt of another referral form along with the
supporting clinical documentation the service will be reviewed for medical necessity.
The PCP and member will be notified of the outcome of the review.


Standing Referrals

Standing referrals are given for long-term therapy with Medical Director approval. See

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Policy & Procedure UICPG UM 006

Urgent and Emergent Requests

Urgent/emergent referrals are generated by the PCP and processed without going through
the medical review process. These referrals will be approved and processed within 24
hours of request.

Upon receipt of the request, eligibility and benefit coverage/limitations is verified. After
processing the request, the requesting PCP and provider of service of the authorization
will be notified by telephone and/or fax.

Out-of-Network Referral Guidelines

The referral process will be followed for all out-of-area/out-of network referrals. In the
event a referral is requested for services out of the referral network the request will be
reviewed in consideration of the following:
     Medical services not available within the network
     Rational for traveling out-of-area not within the network
     Circumstances necessitating patient to select care i.e. auto accident, ambulance
     Medical Directors discretion

Non-Behavioral Decision Requirements

Prospective/Precertification/Pre-Service Process

Prospective/Precertification/Pre-Service Process includes determination of medical
necessity and appropriateness of service and site of inpatient and outpatient services. It is
performed by the UR Coordinator and/or the Medical Director using nationally
recognized medical criteria (Milliman & Robertson). Policy and procedures may be
developed for services not requiring pre-certification.

Precertification/Certification includes documentation of the following:

       sources of relevant clinical information utilized (medical record, physician
        information, labs/test results/x-rays, other)
       estimated length of stay (admission)
       medical criteria met including criteria code (admission)
       non-urgent pre-service determination (approval or denial) within 5 calendar days
        of receipt or request, including the collection of all necessary information (no
        additional time is allowed for obtaining information)

       non-urgent pre-service member notified within 5 calendar days of receipt of
        request


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       non-urgent pre-service practitioner notified within 5 calendar days of receipt of
        request
       urgent pre-service determination (approval or denial) within 72 hours of receipt of
        request, including the collection of all necessary information (no additional time is
        allowed for obtaining information)
       member is notified of urgent pre-service determination within 72 hours of receipt
        of request
       practitioner is notified of urgent pre-service determination within 72 hours of
        receipt of request

Practitioner notification, if initial notification is made by telephone the following will be
documented:
 Time and date of call
 Name of employee who made the call


INPATIENT INITIAL AND CONCURRENT REVIEW PROCESS

Inpatient initial and concurrent review is coordinated through the team approach, the team
consists of, but is not limited to the following members: patient, case manager, PCP,
consultant, health plan case manager, and facility UM staff.

Nurse case manager performs initial and concurrent review on hospitalized managed care
patients. All admissions are entered into the Admission Log. Inpatient reviews are
received via telephone by the Case Manager from the hospital/facility UM staff.

All hospital days are reviewed for appropriateness. Initial review of pre-certified elective
admissions would be deferred until assigned LOS for the admission has reached its limit.

Certification/Initial Review Process Admissions

Emergent Admissions are to be completed within 24 hours of admission or notification
of admission and includes documentation of the following:

   Um decision (approval or denial) made within 24 hours of receipt of the request
   Nationally recognized medical criteria being met (code documented) in justification
    of medical necessity issues
   Assigned length of stay
   Notification of member within 24 hours of the receipt of request
   Notification of practitioner(s) within 24 hours of the receipt of request
   Discharge planning/case management needs addressed

Practitioner notification, if initial notification is made by telephone the following will be
documented:
 Time and date of call

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   Name of employee who made the call

Initial Review Precertification/Pre-service Non-urgent (Elective) Admissions can be
deferred until assigned length of stay for that approved admission has reached its limit.
The completed certification form for admissions (excluding those identified by UICPG
as not requiring review) will include the following:

        Name of patient
        Subscriber I.D. number
        Date of request
        Insurance
        Name of Physician-PCP and/or specialist
        Diagnosis and ICD-9 code
        Procedure-date of procedure and CPT code
        Admit date
        Facility/agency name
        Clinical information-supporting admission with medical history
        Relevant clinical information source
        Medical criteria (nationally recognized) met and code
        Anticipated length of stay
        Physician notification date
        Discharge plan
        Case Management referral, if applicable

All admissions will be included on the admission log with the patient name, date of
admit, diagnosis and discharge date. All admissions (including hospital, SNF, HHC,
Rehabilitation) may be included on the same log.


Concurrent Review Process

The established process provides for review of all continued stay situations (excluding
those identified by UICPG as not requiring review)and includes the following
documentation:
 UM decision (approval or denial) made within 24 hours of receipt of request
 Sources of relevant clinical information utilized (medical record, physician
   information, labs/test results/x-rays, other)
 Nationally recognized medical criteria being met (code documented)
 Additional criteria used in decision-making
 Assigned length of stay that is consistent with criteria
 Notification of practitioner(s) within 24 hour time frame
 The practitioner assumes approval of continued stay, therefore, the practitioner does
   not need to be notified of continued stay approval
 Discharge planning/case management needs addressed


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   Case review prior to the expiration of the current certification, or prior to the
    anticipated discharge date, to determine need for continued stay

If requested service (pre-service, initial review, concurrent stay) does not meet
nationally recognized medical criteria the following must also be documented:

        Date sent to Medical Director or Physician Advisor
        Documentation or relevant clinical information supporting approval or denial
        Documentation of clinical information sources use, such as medical record, lab,
        PCP
        Date additional clinical information request, date received
        Decision rendered and documented within 24 hours of receipt of the request
        Medical Director/PA signature and date
        Member notification (only if denied) within 24 hours of receipt of the request
        including date and information regarding the expedited appeal process.
        Documentation by staff member contacting the member will reflect this.
        Physician notification including date and information regarding the expedited
        appeal process. Documentation by staff member contacting the physician will
        reflect this.

If Medical Director/Physician Advisor review results in a denial, see Denial/Appeal
section (page 25-28)

Certification decisions will not be reversed unless UICPG and the Medical Director
receive new information that was not available at the time of the initial determination.
An approval decision cannot be reversed.


CLOSURE OF A CASE DUE TO INSUFFICIENT INFORMATION (see attached
Policy and Procedures UICPG UM-002 & UICPG UM-003)

Discharge Planning

Potential case management/discharge needs should be evaluated upon admission,
and continuously as part of the concurrent review process. Discharge plans will be
documented on the Concurrent Review sheet. The Case Manager will coordinate
discharge plans with the PCP, consultants, facility Discharge planning personnel, and
health plan case managers as indicated.
Planning includes the following:
 Assessment of patient needs, including psychosocial, home care, equipment, supplies
 Development of discharge treatment plan
 Implementation of service(s) and plan
 Ongoing monitoring of the effectiveness of the plan
 Evaluation of the outcome


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The Case Management Nurse will assist the patient, as appropriate, with follow-up
appointments, referrals, HHC and/or DME needs.

Patients requiring short-term skilled nursing (SNF) care, rehabilitation care, and/or home
heath services will be referred to network facilities and/or agencies. In order to determine
compliance with medical guidelines, initial review of home health services will occur
after the initial patient evaluation/assessment and concurrent review will be contingent
upon the patient’s needs and goals.

Retrospective Review/Post-Service Process

The retrospective review process requires a decision within thirty (30) days of receipt of
the request. If the decision results in a denial, the member and practitioner(s) will be
notified in writing by mail, fax, or e-mail within thirty (30) days of the receipt of request.
The member should not be sent a denial letter when services have already been delivered
in an inpatient setting.

Illinois Department of Insurance Requirement

Utilization Management, including but not limited to prospective, initial, concurrent and
retrospective review, case management, referrals, and/or discharge planning, must be
performed by a URO (Utilization Review Organization) that is registered annually with
the Illinois Department of Insurance. UICPG has delegated the UM functions to Apex
Healthcare. Apex HealthCare has submitted the application and all necessary documents
to Illinois Department of Insurance. Upon review and approval of the completed
application the Department of Insurance will issue the certification to Apex. Proof of
registration will be submitted to the HMO with the UICPG Plan.

Transition to Other Care/Exhaustion of Limited Benefit

Transition of care is applicable when a member is new to the HMO, is displaced by
physician de-participation, or is displaced by termination of a MG/IPA contract. New
members must request transitional services within 15 days of eligibility and existing
members within 30 business days after receiving notification of displacement. Members
in one of these situations who are receiving frequent or ongoing care for a medical
condition or pregnancy beyond the first trimester may request assistance to continue with
established specialists for a defined time. Such members should be directed to the HMO
Customer Assistance Unit for help in this matter.

There are limited benefits for outpatient rehabilitation therapies, infertility services, and
outpatient behavioral health services. Once a member has exhausted a limited benefit, the
UICPG must document this in writing to the member within two business days. A copy
of the communication must be submitted to the HMO. The written communication must
include:
a) the fact that benefits are exhausted;

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b) PCP name;
c) appeal rights and procedure;
d) reminder that the charges incurred beyond the contract limits are the member’s
   financial responsibility; and
e) an offer to educate member about alternatives to continuation of care and ways to
   obtain further care as appropriate.

DENIAL PROCESS- Non-Behavioral Health

The following plan describes the method for processing non-behavioral health denials and
subsequent appeals. This process applies to all services included in the UM Plan and must
meet the following requirements:

1. The Medical Director and/or P.A will review any case that does not meet nationally
   recognized medical criteria. The decision will be rendered and documented within the
   appropriate UM time frame as follows:
    non-urgent pre-service - within 5 calendar days of the receipt of request
    urgent pre- service - within 72 hours of the receipt of request
    concurrent - within 24 hours of the receipt of request

2. The Medical Director or Physician Advisor will determine whether the care should be
   approved or denied.

3. All denied cases, including concurrent review, practitioner(s) and member will be
   informed of the expedited appeals process. The UICPG staff member making the call
   if initial notification was made by telephone will note the expedited appeal process.
   The member and practitioner(s) will be sent confirmation by mail, fax, or e-mail of
   the original notification within the appropriate time frame with inclusion of
   information on the expedited appeal process.

4. The denial must include documentation of the relevant clinical information
   supporting the decision and its source(s) (e.g. medical record, lab results, and
   information from the PCP).

5. If more clinical information is requested in order to make a denial decision, the dates
   the information was requested and received will be documented.

6. When the HMO Scope of Benefits (Guidelines for Benefit Interpretation) is used to
   support a denial decision, a copy of the page of the Provider Manual will be attached
   and included as part of the denial file.

7. Medical Director/PA denial documentation will include one of the following:
   physician’s handwritten signature or initials, e-mail documentation from the
   physician, or unique electronic identifier on the letter or a signed or initialed note
   from an UM staff person, co-signed by the specific physician.

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8. The Medical Director will be available by telephone for the Practitioner(s) to discuss
   denial decisions. UICPG notifies practitioners of its policy for making a reviewer
   available to discuss any UM denial decisions in a newsletter, direct mailing, and/or
   orientation. A denial/appeal log will be maintained monthly.

9. All denials will be included in the log with the reason for denial identified. All
   denials will be clearly identified by type on the log, i.e. medical necessity, benefit,
   out-of-network, etc. NOTE: Referrals written by the PCP to an out-of-network
   provider, then redirected to an in-plan provider are denials and must be documented
   on the denial log. The HMO denial/appeal process must be followed for these out-of-
   network referrals.

10. If no denials have been logged for the month, that will be documented on the log.

11. Denial/ appeal logs (and medical necessity denial files) will be submitted to the HMO
    Nurse Liaison by the 10th day of the month following the end of the quarter. Failure
    to meet this deadline will result in an HMO Administered Complaint. The HMO will
    review the denial/ appeal logs and contact the MG/ IPA with the additional denial
    files (out-of-network and benefit) needed for review. The additional files must be
    submitted to the HMO within 10 business days of the request.

Written Denial Notification

Non-behavioral health denial decisions will be communicated to the member and
practitioner in writing, and within the appropriate time frames. The HMO sample letters
will be used for denials and will include:

1. reason for denial, including an understandable summary of the UM criteria upon
   which denial was based (i.e. a statement in laymen’s terms as to why the service was
   denied);
2. reason includes a reference to the benefit provision, guideline, protocol or other
   similar criterion on which the denial decision is based;
3. appropriate alternative care recommendations;
4. the means by which the Medical Director may be contacted to discuss denial
   decisions;
5. notification that the member may obtain a copy of the benefit provision, guideline,
   protocol or other similar criterion on which the denial decision is based, upon request;
6. description of appeal rights, including the right to submit written comments,
   documents or other information relevant to the appeal;
7. explanation of the appeal process, including the right to member representation and
   time frames for deciding appeals;
8. if the denial is an urgent pre-service or urgent concurrent denial, a description of the
   expedited appeal process will be included.



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Appeal Process

The HMO does not delegate Member appeals to the UICPG; however, UICPG may
have a voluntary appeal process for the Member.

UICPG is responsible for explaining all levels of appeal (pre-service, post-service,
expedited and external appeal process) and the appeal process to the HMO member.

UICPG Medical Management Committee provides practitioner(s) and members with an
appeals process for all denied services. (See Policy & Procedure UICPG UM-004) The
HMO provides a separate appeals process for any member whose issues are not resolved
at the medical group level.

All levels of appeal may be initiated by either the member, the practitioner(s) acting on
behalf of the member, or other member representatives.

Member and Practitioner Appeal Process

The UICPG procedures for initiating an appeal will be listed within the new member
welcome letter. In addition, UICPG is responsible for explaining all levels of appeals and
the appeal process to the HMO member.

When a final determination is made, a written response must be sent to the practitioner(s)
and member which describes the decision of the appeal body and options for a second
level of appeal to the HMO.

Retrospective (post-service) member appeals are allowed.

Pre and Post service appeal policy and procedure is attached (UICPG UM-004).

Expedited Appeal

An expedited appeal may occur if proposed or continued services pertain to a medical
condition that may seriously jeopardize the life of a member; or the member has received
emergency services and remains hospitalized.

If the member is hospitalized, the member may continue to receive services with no
financial liability until notified of the decision.

The expedited appeal process defines the procedure the physician, member or member
representative should follow at the time they are notified of a denial of the proposed



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services, of urgent care or of concurrent review decisions. See attached policy and
procedure UICPG UM-005.


External Appeal

Requests from the Practitioner(s) and/or member for an external appeal will be directed to
the HMO.

An administrative (non-clinical) denial will occur when:
   1. The member is no longer eligible with his managed care plan.
   2. The service requested is not a covered benefit.
   3. The service requested exceeds the member’s benefit limitation.

New and Existing Medical Technology

UICPG will contact the HMO with any questions regarding new and existing medical
technologies.

Satisfaction with the UM Process

Either the HMO or UICPG can perform annual surveys for evaluating member and PCP
satisfaction with the UM process. UICPG is required to discuss the HMO’s survey
results, perform interventions, and evaluate the results of the intervention,
especially specific to PCP referral satisfaction.

Emergency Services

When making UM decisions related to emergency services, UICPG can not deny
emergency services and is contractually required to follow the “prudent layperson”
standard.

Pharmaceutical Management

UICPG will comply with the Pharmacy benefits as designated by the individual managed
care plans.

Protected Health Information

UICPG will follow the provisions for the use of Protected Health Information identified
below and also requires any sub-delegates to follow these provisions (see Policy &
Procedure Apex UM 2):
a) use Protected Health Information (any member identifiers that can be linked to a
    member) only to provide or arrange for the provision of medical and behavioral health
    benefits administration and services;

University of Illinois Chicago Physician Group   28
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b) provide a description of appropriate safeguards to protect the information from
   inappropriate use or further disclosure;
c) ensure that sub-delegates have similar safeguards;
d) provide individuals with access to their Protected Health Information;
e) inform UICPG if inappropriate uses of the Protected Health Information occur; and
f) ensure that Protected Health Information is returned, destroyed or protected if the
   contract ends.


Delegation of UM

UICPG delegates the day to day operations of medical utilization management to Apex
HealthCare. Apex HealthCare is obligated to meet the requirements, standards and time
frames as outlined and described in UICPG’s UM Plan. The contract identifies the
accountability of UICPG and Apex Health Care, as well as the mechanisms for oversight.
UICPG is responsible for review and approval of the sub-delegate UM Plan (when
indicated) through the Medical Management Committee.
If UICPG changes contract management firms, or initiates sub-delegation mid-year, the
HMO must be notified within 30 days. The HMO may request a new UM Plan from
UICPG and/or sub-delegate. The sub-delegate UM Plan and a completed HMO
Compliance tool must be submitted by the HMO required date.

Mechanisms for oversight must include, but are not limited to:
a) annual approval of the sub-delegate UM Plan;
b) annual evaluation of sub-delegate against HMO and UICPG requirements;
c) review of quarterly submissions and any reports; and
d) identification of any deficiencies with corrective action.

A pre-delegation evaluation of the proposed delegate must be performed prior to
delegation to ensure compliance with HMO and UICPG requirements.

HMO Oversight of MG/ IPA/PHO

The HMO Staff will review required MG/IPA submissions quarterly, semi-annually, and
annually as outlined in the MSA and HMO UM Plan.

The HMO provides regular feedback to the MG/IPAs with monthly paid claims and
quarterly utilization reports. HMO Staff review specific utilization trends including
medical, surgical, outpatient surgery, home health, and mental health with MG/IPA Staff.
Individual MG/IPA performance is compared to its previous performance and to the
performance of other MG/IPAs within the network.

For selected MG/IPAs, the HMO will implement educational interventions to assist their
progress. These interventions may include comprehensive and detailed UM in-services,



University of Illinois Chicago Physician Group   29
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focused educational activities targeted to specific problem areas, document review and/or
on-site UM assessment.

The HMO provides an opportunity for discussion of important utilization issues through
practitioner conferences. In this forum, best practices are discussed and MG/IPA input is
obtained. The HMO may conduct focus groups with the MG/IPAs.
Through selected QI indicators and studies, the HMO has the opportunity to monitor the
network for issues relating to over-utilization and/or under-utilization of services. This
review, discussion and monitoring includes utilization data across practices and
practitioner sites. This monitoring information is used to evaluate effectiveness of the
processes used to achieve appropriate utilization. Where specific outcomes are relevant
to a single MG/IPA, this is communicated to the MG/IPA Medical Director and
considered in the recredentialing and reappointment process.
By contract the HMO reserves the right to have HMO staff attend the MG/IPA’s UM/QR
Committee meetings in order to observe and assess the MG/IPA’s internal processes and
activities, and then to provide feedback to the MG/IPA about these processes and
activities. The HMO has the responsibility to ensure that the delegated UM activity is
performed according to the requirements of the HMO UM Plan and MSA.

Under the supervision of the Medical Director, a Nurse Liaison will review and approve
each MG/IPA UM Plan, conduct an annual audit of the MG/IPA UM activities, review
and analyze UM statistical reports, and oversee specialty networks and programs. The
contracted entity is responsible for UM activities at all of its MG/IPA sites.
Any significant substandard performance from the HMO requirements will be reported to
HMO management. The MG/IPA is required to create an action plan that includes more
detailed review and appropriate educational interventions. The HMO then monitors this
plan. The HMO will assess the effectiveness of the interventions. Continued non-
compliance may result in the assignment of an HMO Administered Complaint and
possible default of the MSA.

Annual MG/IPA/PHO UM Audit Preformed by the HMO

The annual adherence audit assists in determining MG/IPA compliance with HMO
requirements. A Nurse Liaison performs the audit of MG/IPA UM activities. The UM
Compliance Site Visit Report Tool is used to measure compliance with HMO UM
requirements. Audit scoring methods are reviewed with the MG/IPA at the time of the
audit. The MG/IPAs receive a written report on the day of the audit.

Any MG/IPA that receives a failing score on this audit is required to submit a corrective
action plan within 30 (thirty) days of the date on the audit results letter. The corrective
action plan must meet guidelines established by the HMO. The Nurse Liaison monitors
receipt of the corrective action plan and reviews it for completeness once it is approved
and implemented. A re-audit is performed to re-measure compliance with HMO UM
Guidelines. MG/IPAs that do not meet corrective action requirements or fail the re-audit



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may be placed in default of the MSA. Should this occur, specific default provisions of
the MSA are enforced.

The annual audit consists of UM Committee Activity review and Case File review. UM
Committee review is performed through review of monthly MG/IPA UM Committee
meeting minutes. This Committee is required to meet at least monthly to review and
discuss UM activities. The minutes of the committee meeting are to show documentation
of the following:
a) Date of the meeting
b) Chairman and members present, including at least one specialist
c) Minutes signed by the Medical Director/Chair within five (5) weeks of the
    date of the last meeting.

The following must be presented in MG/IPA/PHO UM Committee meetings:

ANNUALLY:

Review and approval of the MG/IPA UM Plan including Behavioral Health.

Review and acceptance of medical criteria (including behavioral health and any
additional criteria).

Evaluation of the UM program and progress in meeting determined goals. All goals
identified for the year must be discussed. Interventions implemented, successful
outcomes, and further opportunities for improvement should be discussed.

The UM Committee must document review of the annual HMO member complaint report
in the minutes.

Review and revision of all UM related policies and procedures. Policies must include,
at a minimum: Name of policy, effective date, most current revision date, signature
of reviewing and approving authority. Policies should include, but are not limited to
the following:
1. UM staff on-site review at facility
2. Staff orientation/training/performance review
3. Diagnoses, procedures, physicians not requiring pre-certification and/or concurrent
    review, if applicable
4. Diagnoses, procedures, physicians not requiring pre-certification and/or
    concurrent review, if applicable
5. Additional criteria, clinical pathways, guidelines used for UM decision-making
    and the process for development and approval, if applicable
6. Case closure due to insufficient information
7. Standing referrals
8. Appeals
9. Protected Health Information

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10. Confidentiality
11. Information systems, security, integrity, storage, disaster recovery
12. Tracking avoidable days for medical group physicians and method for corrective
    action and non-compliance


Review and discussion of the HMO PCP UM Survey and Member survey reports,
specific to referral question responses and any other areas for improvement.
Interventions must be documented with follow-up of results.

Review and discussion of Member satisfaction with referrals form HMO Member
satisfaction by medical group survey. Interventions must be documented with
follow-up of results.

SEMI-ANNUALLY:

Identification, analysis and development of interventions for improvement relating to the
utilization statistics studies on trends, patterns and/or physician practice patterns. If no
interventions are needed, this must be documented. UICPG will track at least four of the
following, including one for behavioral health: inpatient days/1000, admits or
discharges/1000, behavioral health days/1000, average length of stay, rates for types of
procedures. Any occurrences of under or over utilization must be noted. Analysis must
include comparison of past quarters (at least 6 months of data).

Summary of avoidable inpatient days and reasons for delayed discharge. UICPG
Physicians identified with avoidable day practice pattern trends must be identified
in Medical Management Committee with documentation of corrective action
according to the UICPG policy.

Discussion of referral statistics (including behavioral health) with a two quarter referral
comparison, trending, analysis, and discussion documented in the minutes (at least 6
months of data). Interventions must be documented for any trends noted. If there
are no referrals for the month, that is to be documented in both minutes and on the log.
Dermatology, Urology, and all out-of-plan referral logs are to be maintained monthly and
submitted to the HMO upon request. Mental Health referral logs are to be maintained
monthly, regardless of whether UICPG or a CMF manages behavioral health care, and
submitted to the HMO upon request.

Inter-rater reliability testing for criteria utilization (Medical Director, PA(s) and UM
Staff) and decision making timeframes (UM Staff). A summary of the results and
number of cases by reviewer(s) must be included in the minutes. Include any corrective
action.

QUARTERLY:


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Quarterly, the Medical Management Committee must review and discuss all complaints
received by the group related to HMO members including: complaints received at the
MG/IPA, Quality of Care complaints received at the MG/IPA and/or Quality of Care
complaints forwarded to the MG/IPA by the HMO, and HMO Administered complaints.
These may be discussed in summary format using categories of complaints; such as:
access, PCP issues, etc. A monthly log of these complaints must be maintained. The
complaints must be resolved within 30 days. Resolution of the complaints and the
timeframe must be documented on the log or in the minutes. If there are no
complaints for the month, that is to be documented in both minutes and on the log.

Quarterly review and discussion of any sub-delegate, CMF, behavioral health sub-
delegate including review of any submissions, reports from the sub-delegates, if
applicable. CMF quarterly reporting must include reference to telephone statistics
and compliance with HMO standards.

Quarterly discussion of the HMOs’ review of UICPG denial files, any non-
compliance and corrective action, if required.


MONTHLY:

The MG/IPA must discuss any potential long-term inpatient cases, readmissions, or any
cases or cases requiring coordination of care should also be discussed in the minutes.

The committee must review and discuss all denied/appealed services to insure denials
have been appropriately managed according to MG/IPA’s established procedures and
HMO policies, including application of written nationally recognized medical criteria.
Denial discussion must include a summary of the category of denials (BH and non-
BH: medical necessity, out-of-network, and benefit), number in each category,
timeframes compliance, and resolution.

Note: Denial files (medical and behavioral health) are reviewed as requested (monthly
or quarterly) after submission to the HMO with the denial logs.

Case file review is performed by the Nurse Liaison by randomly choosing 10-15 case files
from UICPG’s admission logs at the time of the audit. The cases are reviewed against
HMO standards for medical criteria, time frames, documentation of clinical source, etc.
Specialist referrals are chosen and reviewed for adherence to HMO requirements.


ADDITIONAL UM REQUIREMENTS/ ACTIVITIES

Reporting of All Ambulatory Services provided either directly by the Practitioner(s) or
by referral from the PCP. Semi-annually the UICPG will provide to the HMO summary


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encounter data listing the top 10 (ten) ambulatory diagnoses by frequencies and top 5
(five) specialty referral types by frequency.

Confidentiality Policy and Procedure (Attached UICPG Confidentiality) will be
provided to the HMO outlining the protection of patient and provider specific information
collected during the utilization review process.

Information system maintenance, the system must provide for data security, integrity,
storage and a written disaster recovery plan. (See Policy and Procedure Apex Data
Protection & Back Up Program)

Maternity Discharge Program to help manage utilization. This program should be
included within the Utilization Review process. The following elements are required for
an acceptable HMO OB Discharge Plan:

a) Documentation of pre-natal education with the mother and information about the OB
   Discharge Program during the first and second trimester

b) Documentation of eligibility criteria related to the OB Discharge Program

c) Arrangements for an infant examination either by a Practitioner or by a Nurse visit to
   the home within 48 hours after discharge from the hospital must be offered if the
   infant is discharged less than 48 hours after vaginal delivery or less than 96 hours
   after Cesarean delivery.

Individual Benefit Management Program (IBMP), benefits may be provided for
services that are not covered services under the Certificate of Health Care Benefits.
Reference may be made to the MSA and the BlueCross/BlueSheild HMOs’ Policy and
Procedure manual for more detailed information.

Infertility Benefits are covered services for the member from the HMOs. The PCP or
the WPHCP may establish a diagnosis of infertility. Once this diagnosis has been made,
a referral is required for these services to be in benefit.

Organ Transplants UICPG is responsible for monitoring all aspects of clinical care
including referral, pre-certification, and concurrent review related to organ transplants.
UICPG Case Manager will notify the HMO Nurse Liaison prior to the member’s
evaluation at a BCBS transplant network facility. The Nurse Liaison will confirm that the
facility is currently in the HMO transplant network for the relevant organ. If the member
is accepted as a transplant candidate, the Case Manager should forward certain documents
to the Nurse Liaison for the HMO medical review. These documents include the
member’s history, the reason for transplant, a letter from the PCP indicating his/her
approval, and a letter from the transplant facility confirming the member’s transplant
candidate status. After the HMO review, the Nurse Liaison will provide a letter of
authorization or a written denial to UICPG.

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Out-of-area admissions The HMO is financially responsible for out-of-area admissions
where members are admitted for an emergency condition or a life-threatening situation
more than 30 miles away from UICPG. UICPG retains responsibility for monitoring
clinical aspects of care and for arranging the transfer of the member back into plan once
clinically appropriate. When the treating physician PCP determines that the member is
medically stable for transfer, UICPG Case Manager notifies the PCP that the member can
be brought back into plan within 1 (one) business day of UICPG notification. Refer to
Termination of Benefits section for protocol of issuing TOB if member refuses to transfer
in-plan.

Out-of-Network admissions are urgent or emergent admissions that are within 30 miles
of UICPG and occur without UICPG prior approval. UICPG’s responsibilities include:
As soon as UICPG becomes aware of the admission, the Case Manager will obtain an
initial review and patient information including the following:

a) Monitoring of care to determine when the member is stable.
b) When stable, facilitates the transfer of the member to an in-plan or in-network facility
c) Contact the member concerning the decision to transfer

The PCP must be notified of the admission within 1 (one) business day of UICPG
notification. If the local attending physician and PCP agree that the member is medically
stable for transfer, an attempt must be made to bring the member into plan. The TOB
process may be utilized if the member refuses to transfer.

Termination of Benefits (Applies to Medical as well as Mental Health Admissions)
UICPG will not terminate inpatient benefits of any type without the concurrent
authorization of the HMOs.

TERMINATION OF BENEFITS FOR SERVICES                               NOT     MEDICALLY
NECESSARY AT GROUP APPROVED FACILITY

When UICPG/PCP is notified of a member’s admission to a group approved facility, the
PCP must contact the attending physician within 2 (two) working days of the notification
of the admission to determine medical necessity. If it is determined that services are no
longer medically necessary and the member refuses to be discharged, the following
process is begun:

a) The PCP communicates the member’s refusal to the UICPG Case Manager and/or
   Medical Director. A written statement from the PCP must indicate that continued
   services for the member are no longer medically necessary

b) The Case Manager must report the case to the HMO through its HMO Liaison or
   HMO UM Manager



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c)   The HMO Liaison must receive the PCP written statement prior to acting on the
     MG/IPA request to terminate benefits

d)   HMO UM Manager and/or the Medical Director will review the submitted
     documentation

e)   The member must receive written notification from the UICPG stating that the PCP
     has determined that continued services are no longer medically necessary and are not
     group approved after a stated date. This date cannot be less than 24 hours following
     the member’s receipt of the determination

f)   UICPG submits a copy of the letter to the business office of the facility, the PCP, the
     UICPG Medical Director and the HMO Liaison

g)   The HMO Liaison distributes copies of the letter to the HMO Network Consultant,
     HMO UM Manager, and the Medical Director

h)   Upon receipt of the letter, the HMO Liaison notifies the member of the denial of
     benefits for the non-group approved services

i)   The HMO Nurse Liaison will send a copy of this letter to the business office of the
     facility, the PCP, UICPG Medical Director, UICPG Case Manager, HMO UM
     Manager, HMO Network Consultant, HMO Medical Director, and HMO Claims
     Department.


TERMINATION OF BENEFITS FOR MEDICALLY NECESSARY CONTINUED
SERVICES AT A NON-GROUP APPROVED FACILITY

When a UICPG/PCP is notified of a member’s medically necessary admission to a non-
group approved facility, the PCP contacts the attending physician within 2 working days
of the notification of the admission to the facility. In the event the member is determined
by the attending physician and the PCP to be medically stable for transfer but the member
refuses to transfer to an in-plan hospital, the following process is begun:

a) The PCP must communicate this determination and situation in a written statement to
   the UICPG Case Manager and/or UICPG Medical Director in a timely manner.

b) The Case Manager must report the case to the HMO through their HMO Nurse
   Liaison or HMO UM Manager.

c) The HMO Nurse Liaison must receive the PCP’s written statement prior to acting on
   UICPG’s request to terminate benefits.




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d) The HMO UM Manager and/or the HMO Medical Director will review the submitted
   documentation.

e) The member must receive notification from UICPG stating that the PCP has
   determined continued services are only covered in plan and are not group approved in
   the current facility after a stated date. This date cannot be less than 24 hours
   following the member’s receipt of the determination.

f) UICPG will a copy of the letter to the business office of the facility, the PCP, UICPG
   Medical Director and the HMO Nurse Liaison.

g) The HMO Nurse Liaison distributes copies of the letter to the HMO Network
   Consultant, HMO UM Manager and the HMO Medical Director.

h)   Upon receipt of the letter, the HMO Nurse Liaison notifies the member of the denial
     of benefits for the non-group approved services.

i)   The HMO Nurse Liaison will send a copy of this letter to the business office of the
     facility, PCP, UICPG Medical Director, UICPG Case Manager, HMO UM Manager,
     HMO Network Consultant, HMO Medical Director, and HMO Claims Department.

j)   When UICPG is notified that a member is receiving care at an out-of-area facility, the
     member’s condition should be monitored to determine stability for transfer to an in-
     area facility. Once medical stability is determined, transfer to an in-area facility
     should be considered.




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