Providence Health Plans 2005 Quality and Utilization Management

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					                     Providence Health Plans
              2005 Quality and Utilization Management
                        Program Description

                                       Table of Contents


1.0 Philosophy and Purpose                                  2

2.0   Program Goals                                         2

3.0   Program Authority and Responsibility                  3

4.0   Program Structure                                     3

5.0 Quality and Utilization Management Standards            9

6.0   Program Components                                    11

7.0   Data Sources and Analysis                             15

8.0 Quality and Utilization Management Program Evaluation   15

9.0   Confidentiality                                       16

10.0 Conflict of Interest / Ethics and Accountability       16

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1.0 Philosophy and Purpose

The Quality and Utilization Management Program maximizes health outcomes and assures quality care
to our members through an array of programs and services designed to meet the health care needs of
the populations we serve. Health Plan population data and industry health care trends and practices
guide the selection and development of programs and services provided for or offered to members.
These programs and services focus efforts on identification and management of conditions and
illnesses that would benefit from appropriate, timely, and robust interventions. The Quality and
Utilization Management Program promotes continuum of care principles, integrating a range of
programs and services appropriate to meet the needs of individuals and specific populations.

The Quality and Utilization Management Program is driven by Providence Health System’s Mission
and Core Values and is committed to meeting community health care needs by focusing on outreach,
affordability, and excellence. Providence Health Plans is distinguished from other health plans by the
sponsorship of Providence Health System.

    1.1 Scope

    The Quality and Utilization Management Programs serve the membership of the Health Plan. The
    program includes:
      Pre-certification of select inpatient and ambulatory services and out-of-plan/out-of-area care
      Concurrent review and discharge planning in hospitals, skilled nursing facilities, and ancillary
      care settings
      Complex case and disease management
      Clinical audit of high dollar claims, facility claims, select modifiers, and targeted
      Analysis, monitoring and program development related to utilization, cost, and quality trends
      Delegation oversight
      Quality improvement activities
      Credentialing and peer review
      Behavioral health

2.0 Program Goals

The goals of the Quality and Utilization Management Program are to prevent illness, improve health
and patient safety, manage disease, and provide effective stewardship of health plan and community
resources. The goals are met through the following objectives:
  Development of programs and interventions to address opportunities for improvement in areas of
  health care and financial stewardship
  Evaluation of health care services for quality, medical necessity and appropriate level of care
  Adoption and implementation of interventions that promote effective management and outcomes of
  care, including encouragement of prevention and early detection of disease
  Establishment of guidelines and policies that support consistent and equitable allocation of medical
  Ensure delegated entities have adequate systems and resources to meet quality of care and service
  demands in a cost effective and efficient manner
  Support providers’ participation in local and national patient safety initiatives

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  Meet or exceed the expectations and standards of Federal and State regulatory bodies, accrediting
  organizations, and our contracted provider network and members
  Annual evaluation and review of the effectiveness of the Quality and Utilization Management

3.0 Authority and Responsibility

The Providence Health Plan Advisory Board is the governing body for the Health Plan. The Advisory
Board approves the quality and utilization management strategic plan and annual goals and objectives.
It approves quality plan directions, quality monitoring and reporting systems, and approves regulatory
and accreditation compliance while providing fiduciary oversight. The Advisory Board has designated
the Administrative Quality Council as the body that oversees the implementation of the Quality and
Utilization Management Program and Work Plan, including allocating resources and ensuring follow-up
on identified issues. The actions of the Advisory Board are reviewed for approval by the PHS Board of
Directors. The Chief Executive Officer is the executive sponsor of AQC and a member of the
Advisory Board.

The Regional Director of Operations is the designated senior executive responsible for the operational
(service improvement) aspects of quality and also sits as a member of the Service Improvement Team,
Administrative Quality Council, and the Advisory Board.

The Chief Medical Officer is the designated senior executive responsible for the Quality and Utilization
Management Program. The Chief Medical Officer is responsible for assuring that mechanisms are in
place to monitor and improve the appropriateness and quality of medical care and service delivered to
members. The Chief Medical Officer sits as a member of the Quality Improvement Team,
Administrative Quality Council, and the Advisory Board.

4.0 Program Structure

The Quality and Utilization Management Program structure is made up of the following components:
    4.1 The Quality Improvement Team
    4.2 The Utilization Management Committee and subcommittees
    4.3 Program Staff
    4.4 Quality and Utilization Management Program Description, Work Plan, and Policies and

    4.1 The Quality Improvement Team

    The Quality Improvement Team is responsible for oversight of all clinical components within the
    organization. The team provides guidance and approval for the Quality and Utilization
    Management Program including the annual evaluation and work plan. It receives reports and
    minutes from the Utilization Management Committee, Quality Medical Standards Committee,
    Service Improvement Team, Medical Policy Committee, Technology Assessment Committee,
    Delegation, Behavioral Health, and Disease Management.

    The Quality Improvement Team responsibilities are:
      Approval of policies and procedures that govern quality management activities
      Oversight of clinical programs including behavioral health activities

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  Guidance regarding new quality initiatives and disease management programs
  Ongoing monitoring through received reports and/or minutes of programs in place to improve
  the health, patient safety, and disease management of Health Plan members

Membership: Chief Medical Officer, Health Plan Medical Directors, Directors of Quality
Management and of Quality Medical Management, Director of Network Development and
Provider Relations, Director of Operations, and representatives of key functional areas within the
Health Plan.
Chair: The Chief Medical Officer
Meeting Frequency: Quarterly

4.2 The Utilization Management Committee

The Utilization Management Committee is responsible for implementation of all aspects of the
Utilization Management Program for all service areas of the Health Plan. This includes both
delegated and non-delegated utilization management activities. This oversight is accomplished
through the work of this committee or one of its subcommittees. Subcommittees include the
Pharmacy Committee, the Technology Assessment Committee, and the Medical Policy Committee.

The Utilization Management Committee responsibilities are:
  Oversight of clinical utilization programs
  Approval of standards, criteria, and policy that govern utilization management practices
  Approval of policy and criteria that govern medical management decisions, including medical
  policy and criteria, drug formulary decisions, and policy/criteria for new technology
  Evaluation of utilization data, especially as it relates to concerns for under and/or over
  utilization of care or services
  Oversight of all delegated utilization management activities to include approval and/or
  revocation of utilization management delegation

Membership: The Chief Medical Officer, Health Plan Medical Directors, Directors of Quality
Management and Quality Medical Management, Health Plan program staff, and representatives of
key operational areas of the Health Plan.
Chair: Health Plan Medical Director
Meeting frequency: Every two months and at least five times per year.

   4.2.1 Pharmacy Committee

   The Pharmacy Committee (Ambulatory Care Pharmacy and Therapeutics Committee) oversees
   PHP’s drug formulary to assure the availability of safe and effective drug choices as well as to
   improve the quality of pharmaceutical care for the membership consistent with the mission,
   goals, and vision of the Providence Health System.

   Membership: The Chief Medical Officer, Health Plan Medical Directors, practicing physicians
   (primary care and specialist), practicing pharmacists, Providence Health System pharmacy
   directors/managers, Pharmacy Director, Health Plan program staff, and an ad hoc psychiatrist.

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Chair: Health Plan Medical Director or designee appointed by the Chief Medical Officer
Meeting frequency: Every two months

4.2.2 The Technology Assessment Committee

The Technology Assessment Committee foresees, evaluates, and monitors new technology for
Health Plan members. The committee reviews related research, consults with specialists, and
oversees the criteria/policy development related to the technology under review.

Membership: The Chief Medical Officer, Health Plan Medical Directors, two participating
physicians, ad hoc specialists, and ad hoc corporate legal counsel. The committee is also staffed
by licensed nurses who are non-voting.
Chair: Health Plan Medical Director or designee, appointed by the Chief Medical Officer
Meeting Frequency: Monthly

4.2.3 Medical Policy Committee

The Medical Policy Committee is responsible for development, review, and revision of medical
policy and criteria and assures that policy and criteria support safe and effective health care.

Membership: The Chief Medical Officer, Health Plan Medical Directors, and practicing
physicians (primary care and specialists), who may be asked to provide input and review for
medical policy and criteria development and evaluation. Ad hoc specialists are also used to
evaluate certain areas related to medical appropriateness. The Chief Medical Officer and the
Medical Directors are the communication link to the Utilization Management Committee.
Chair: Health Plan Medical Director
Meeting Frequency: Monthly

4.2.4 Credentials and Quality Committee

The Credentials and Quality Committee provides clinical oversight of Health Plan providers
with its main purpose being to perform peer review and make recommendations regarding
initial and recredentialing decisions. The committee is responsible for reviewing practitioner and
facility qualifications against established criteria and making decisions regarding approving,
deferring, modifying, or denying participation with the Health Plan. It also makes decisions
about exceptions to criteria and about terminations.

Membership: Health Plan Medical Director, Manager of Credentialing and Quality
Management, Health Plan staff, and up to seven participating practitioners representing a
variety of disciplines.
Chair: Health Plan Medical Director
Meeting Frequency: At least every two months

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4.2.5 Delegation Oversight Committee

The Delegation Oversight Committee provides oversight and direction for delegation
agreements. It provides a forum for discussion of delegation issues including non-compliant
delegates and de-delegation.

Membership: Director of Network Development, Manager of Provider Relations, Manager of
Provider Contracting, Director of Quality Management, Manager of Credentialing and Quality
Management, Director of Quality Medical Management, Manager of Systems Administration,
Director of Operations, Manager of Appeals and Grievance, Manager of PPO, Manager of
MCO, and representation from Regulatory.
Chair: Director of Quality Management
Meeting Frequency: Quarterly

4.2.6 Quality Management Standards Committee

The Quality Management Standards Committee is responsible for the development,
implementation, and measurement of all quality standards in the Health Plan. These measures
reflect both external and internal standards. It submits reports to the Quality Improvement
Team and reports directly to the Administrative Quality Council.

Membership: Representatives of all Health Plan functional areas.
Chair: Director of Quality Management
Frequency: Quarterly

These additional parameters govern the Quality Improvement Team and Utilization
Management Committees and their Subcommittees:

Quorum: A majority of the voting members, including at least one Medical Director, shall
constitute a quorum for the transaction of business.

Agreement: Agreement is reached by consensus of the members in attendance.

Vacancies: Whenever a vacancy occurs in a committee or one of its subcommittees, the Chief
Medical Officer appoints a new member.

Agenda and Minutes: All minutes include a formal agenda as well as the recording of minutes of
activities and recommendations. Committee meeting agendas and minutes are recorded in a
standardized format that reflects activities and ongoing agenda items, and includes conclusions
and actions. A draft of the minutes is verified for content and accuracy and is signed by the
committee chair. Minutes are included in the mailed packet to committee members for review
one week prior to the next meeting. Final approval is given and documented at this committee

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        Minutes from the subcommittees are forwarded to the Quality Improvement Team and/or
        Utilization Management Committee for review. The master copy, as well as all attachments used
        in the original presentation, is maintained within the Quality Medical Management Department.

    4.3 Program Staff

The Quality and Utilization Management Program is staffed by physicians, pharmacists, licensed clinical
staff, and non-clinical staff. Staff receives a formal orientation to the quality and utilization management
programs and activities and to the Health Plan as a whole. Ongoing education is provided or available
through in-house education meetings, outside study programs, seminars, or formal study. Inter-rater
reliability measures are monitored to ensure consistency of decision-making and identify educational

        4.3.1 Chief Medical Officer

        The Chief Medical Officer is the senior executive responsible for the following:
          Population analysis, and development and implementation of medical management programs
          to meet population health care needs
          The appropriateness and quality of medical care and services delivered to members
          Ensuring fair and consistent decision making through the use of evidence-based medical
          policy and/or nationally accepted standards of care, medical criteria, and physician advisors
          Evaluation of new technologies
          The credentialing and peer review program
          Delegated utilization management activities
          Delegated credentialing activities
          The Quality Improvement Team

        The principal accountabilities of the Chief Medical Officer include the day-to-day oversight,
        implementation, evaluation, and improvement of the quality and medical management
        programs, credentialing, the education and counseling of practitioners in the principles of
        managed care, and the promotion of a positive relationship between the Health Plan and its
        practitioners, including delegated entities. The Chief Medical Officer visibly links the Utilization
        Management Program to the Ethics and Accountability Committee, and serves on the
        Utilization Management Committee, the Pharmacy Committee, the Technology Assessment
        Committee, and the Quality Improvement Team. He is also a member of the Administrative
        Quality Council. The Chief Medical Officer is assisted by Health Plan Medical Directors who
        have program and function responsibilities.

        4.3.2 Medical Directors

        Medical Directors have specific functions and program responsibilities. They assist in the
        management of medical activities through program evaluation and design, the development of
        program clinical content and direction, case review, medical necessity review, and medical policy
        development. Medical Directors have responsibility for the Pharmacy Committee, the
        Technology Assessment Committee, the Utilization Management Committee, the Medical
        Policy Committee, and the Credentials and Quality Committee. They also may represent the

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   Health Plan as it relates to the Oregon Health Plan and other external organizations.

   4.3.3 Physician Advisors

   Physician advisors are consulted for case review, medical policy and criteria development,
   evaluation of standards of practice, and for assistance with the interpretation of utilization
   trends and variations. Physician advisors assist with decision making regarding medical
   appropriateness in their area of clinical expertise. Physician advisors may be members of
   committees or may attend a committee by invitation, when needed, for specific case review or

   4.3.4 Staff

   Licensed Clinical Staff
   Licensed clinical staff are responsible for clinical review in prior authorization, concurrent
   review and discharge planning, case/disease management, pharmacy, quality, credentialing, and
   medical claims review. When providing clinical review of service requests, clinical staff may
   approve services based on medical necessity, but do not have the authority to issue denials for
   lack of medical necessity. Clinical staff act as clinical experts/resources for the organization and
   work closely with the quality management staff to provide data in key quality areas, such as peer
   review and over-and under utilization. The clinical staff are responsible for the day-to-day
   operations of the Quality and Utilization Management Program. In medical management areas
   they are accountable through the Director of Quality Medical Management to the Chief Medical

   Non-clinical staff
   Quality and medical management technicians, project managers, and analysts support quality
   and utilization management programs: provide data entry and reporting, assist internal and
   external customers, and manage day-to-day activities. Non-clinical staff may review requests for
   coverage and approve selected services, under written guidelines, but may not issue medical
   necessity denials. Staff follow departmental policies and procedures and external standards.

   Pharmacy Staff
   The Director of Pharmacy, a registered professional pharmacist, directs the pharmacy
   management program and is responsible for program development, implementation, evaluation,
   provider profiling, and education. The Director of Pharmacy is assisted by department
   pharmacists, medical directors, and pharmacy technicians. Pharmacists review and may approve
   requests for drug coverage, but may not make final medical necessity denials.

4.4 Program Description, Work Plan, and Policies and Procedures

The program description, work plan and policies and procedures are the framework under which
the Quality and Utilization Management Program ensures members receive quality and cost-
effective health care. These written guidelines allow us to demonstrate compliance with regulatory
standards. Based on the program evaluation, the program description and work plan are revised
annually, but may also be revised on a more frequent basis as needed. The work plan describes the
scheduled activities related to quality improvement, monitoring, and program infrastructure. The
work plan serves as a guide for quality improvement activities and includes: objectives, activities,
performance goals, accountability, reporting, timelines, and frequency.

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5.0 Quality and Utilization Management Program Standards

Program standards are derived from nationally recognized industry standards including NCQA, CMS,
state insurance code, and internally developed policies and procedures. The program is accountable for
appropriate, fair, and consistent decision making. Program standards, criteria, and policies are reviewed
annually and updated as needed. When credentialing or utilization management is delegated, either
partially or wholly, program standards must be met. Validation of fair and consistent decision making is
accomplished through inter-rater reliability monitoring of all licensed personnel and physicians. This
applies to all decisions rendered including those decisions made by delegated entities.

       5.1 Medical Necessity/Appropriateness Determination

       Medical necessity or appropriateness of health care services is defined in Providence Health
       Plan's medical policy, Definition: Medical Necessity. This policy is disseminated to Health Plan
       practitioners and delegates. This definition is used in the determination of coverage for
       medically necessary health care services. Health care services include medical, surgical,
       behavioral, diagnostic, and/or other health care services, supplies, treatments, drug therapies, or

               5.1.1 Plan Developed Medical Policy and Criteria

               The Utilization Management Committee or one of its subcommittees develops medical
               policy and criteria used for authorizing care. Licensed practitioners, with appropriate
               specialty representation, may participate in development of Health Plan criteria. Policy
               and criteria formulation is based on reasonable medical evidence. There are times when
               nationally accepted criteria are adopted by the Health Plan and included as part of the
               medical policy and criteria. Guidelines for applying criteria, taking into consideration the
               individual needs of the member and the capabilities of the local delivery system, are
               reviewed and approved annually. All policies are communicated to providers via
               ProvLink, an on-line resource, and are reviewed annually and updated as needed.

               5.1.2 New Technology

               New technology and/or new applications of existing technology are evaluated and
               recommended for coverage by the Technology Assessment Committee. Health Plan
               decisions are based on information from multiple sources such as national assessment
               bodies, professional societies, accepted experts in the field, consensus of expert opinion,
               proven health benefit, efficacy, and safety. The following non-inclusive list of
               technology assessment bodies provides information to the Health Plan and guide
               technology coverage decisions:
                 Diagnostic and Therapeutic Technology Assessment (DATTA)
                 National Cancer Institute (NCI)
                 Agency for Healthcare Policy and Research (AHCPR)
                 ECRI Health Technology Assessment Information Service
                 Technologica (BCBSA)
                 Center for Disease Control (CDC)
                 Federal Drug Administration (FDA)
                 SG2 consulting

               The Chief Medical Officer, along with the Technology Assessment Committee, is

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        responsible to research and develop policy regarding new technology. Drug coverage
        issues are reviewed by the Pharmacy Committee, which makes a recommendation to the
        Technology Assessment Committee. The Utilization Management Committee is
        responsible for final approval of coverage for new technology. Approval for coverage
        must meet the following criteria:
           Improves health conditions
           Safe and efficacious
           Beneficial as established alternatives
           In keeping with good medical standards
           Meets government approval to market as appropriate
           Supported by research published in peer review journals
           Cost effective

        Emerging new technology may be given consideration for coverage on an individual
        case basis if the technology is a scientifically established medical treatment, shows a
        demonstrable benefit for a particular illness or disease, is proven to be safe and
        efficacious, and there is no equally effective or less costly alternative. A technology
        coverage decision, which affects the members’ specific benefit, is forwarded to the
        appropriate Health Plan committee for benefit revision and implementation.

5.2 Review Criteria

The Quality and Utilization Management Program utilizes local and national standards and
criteria for fair and consistent decision-making. The Utilization Management Committee
through its Medical Policy Committee is charged with the development and approval of medical
policy and criteria and for the approval of guidelines for the application of these criteria. Criteria
application and medical policy are reviewed annually and updated as necessary. Standards,
criteria, and medical policy are shared with providers, as they are developed and per request.
The application of review criteria is monitored through inter-rater reliability audits performed
on both delegated and non-delegated decision makers.

        5.2.1 Standards

        The Health Plan and/or its delegates rely on various national criteria sources in addition
        to internally-developed criteria for the review of medical appropriateness. Both
        nationally and locally accepted indicators of medical appropriateness (criteria) are used
        in the review process and decision-making. Criteria as a normative standard, provide a
        foundation for utilization management activities and decision-making, and serve to:
           Educate providers and members about utilization expectations
           Provide goals to improve care and processes
           Provide responsible and consistent standards for fair decision making

        Providence Health Plans and/or its delegates rely on various national criteria sources in
        addition to Plan developed criteria for the review of medical appropriateness.

        For concurrent review and case management, length of stay is based on medical need
        established by referencing nationally recognized industry standards and resources, and
        by working in close collaboration with the attending physician. Optimal care and
        discharge planning is managed collaboratively by the attending physician and the Health

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               Plan or hospital clinical staff. Resources consulted include:
                 HCIA Western Region Length of Stay
                 Health Care Management Guidelines, Milliman and Robertson
                 CMS guidelines including Medicare coverage of Skilled Nursing
                 InterQual ISD criteria

               For referrals and prior authorizations:
                 Health Care Management Guidelines, Milliman and Robertson
                 InterQual ISP/ISX criteria
                 CMS guidelines including HCPCS Common Procedure Coding System
                 OMAP (Oregon Medical Assistance Program) Prioritized List of Health Services
                 (Oregon Option Members only)
                 HCIA Western Region LOS

6.0 Program Components

Quality and Utilization Management Program activities are reviewed and revised annually as needed.
Policies and Procedures provide specific standards and processes, such as timelines for decision-
making. Delegation of program components, either partially or wholly, is monitored by the Utilization
Management Committee and the Quality Improvement Team which ensures that Health Plan standards
are being met.

       6.1 Prior authorization

       Prior authorization provides prospective review of selected services and procedures for medical
       necessity determination and benefit coverage and possible referral to other utilization or case
       management programs. Prior authorization is required for selected services and facility
       admissions. This authorization is performed to determine the level of care before an admission
       occurs, and/or to assess the clinical indications and appropriateness of services requested or
       planned. Requests for prior authorization are initiated from the provider or, in certain cases, the

       6.2 Home Health and Durable Medical Equipment

       Services provided in the home, which may include equipment, supplies, skilled nursing, physical
       therapy, occupational therapy, respiratory therapy, and/or intravenous infusion, may be
       reviewed prospectively, concurrently and, in selected situations, retrospectively. Review includes
       evaluation of medical necessity, the appropriate level of care, and the duration of the care.
       Internally developed standards and external guidelines (Medicare) are used in the review

       6.3 Concurrent Review and Discharge Planning

       Licensed nurses conduct onsite and telephonic concurrent review in acute care hospitals and
       skilled nursing facilities. The review establishes medical necessity for the appropriate length of
       stay, setting and services, and facilitates discharge planning needs.

       Discharge planning is done in collaboration with the attending physician, the member, primary
       physician, and ancillary or community providers. The concurrent review nurse screens the

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medical plan of care at the earliest opportunity to determine discharge needs and/or placement.
Early identification and referral of members who would benefit from case management and/or
a disease management program are done concurrently to facilitate coordination and continuity
of care.

6.4 Drug Utilization Management

The Pharmacy Program manages the drug formulary to assure the availability of safe and
effective drug choices as well as to improve the quality of pharmaceutical care for the
membership consistent with the mission, goals, and vision of the Health Plan. Formulary status
is given to drugs that meet evidence-based assessment of therapeutic effectiveness, safety, and
pharmaco-economic value, and offer an important advantage to existing formulary alternatives.
The specific responsibilities of the Pharmacy Program are to identify and develop drug therapy
and medication management initiatives and programs, create drug therapy utilization guidelines
and policies, provide oversight to member and provider education and communication
pertaining to drug therapy, review pharmacy services, surveys, audits and complaints and
provide oversight to prospective, concurrent and retrospective drug use review programs.

6.5 Referral Management

Referrals to Health Plan participating providers and practitioners are managed by the member’s
primary physician when required by the member’s coverage and may be included in delegated
utilization management. Referrals to non-participating providers require review and
authorization by the Health Plan. Exceptions may apply for providers in areas with limited
provider panels.

Referrals to non-participating providers and practitioners are approved when services are a
covered benefit, are medically necessary, and there are no participating Health Plan providers
with the clinical expertise to evaluate and/or manage the member’s care.

6.6 Retrospective Review

Retrospective review occurs after the care or service has been provided. The review may
encompass any level of care and can include auditing claims or bills. Identification of services
requiring retrospective review may occur through standard audit procedures, through
notifications, and/or through claims edit systems.

6.7 Case Management

Case management is a systematic process of assessment, coordination, and intervention related
to a member’s health care needs. Case managers are licensed nurses who work in collaboration
with the member’s primary care or personal physician, attending physician, and health plan
medical directors to provide a coordinated approach to the member’s care needs.

The primary goal of case management is to ensure that care needs are met and that
interventions occur as early as possible, thereby avoiding or minimizing deterioration in health
status, pain, or suffering. This proactive approach uses health risk assessment tools, clinical
practice guidelines, predictive modeling, and other tools for managing care. The objectives of
case management are to:
   Provide a coordinated approach to care planning

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  Use health care resources appropriately
  Provide targeted health education
  Perform risk assessment and evaluation on selected membership
  Provide a linkage to health system and community resources
  Facilitate communication between health plan members and their health care providers
  Educate and empower members to take an active role in the management of their health

As identified, specialized case management services are provided for:
  Those with frequent hospital admissions
  The frail and elderly
  Exceptional needs coordination (for Oregon Option Phase II members)
  High acuity services such as transplants and end stage renal disease
  High risk maternity patients
  High risk cancer patients

6.8 Behavioral Health and Chemical Dependency Services

Utilization management and provision of behavioral health and chemical dependency services
are provided through contracted arrangements. Services include:
  Direct access to behavioral health/chemical dependency treatment
  Triage and referral management
  Approval and monitoring of treatment plans
  Concurrent review and length of stay assessments

6.9 Individual Practitioner Credentialing

The credentialing and recredentialing process supports selection and contracting of
practitioners who maintain the clinical skills and judgment necessary to deliver high quality
healthcare. The process ensures that all practitioners meet specific criteria and standards
including NCQA and CMS. Practitioners are recredentialed at least every three years. Providers
are reviewed by the Credentials and Quality Committee.

6.10 Facility Credentialing

The Health Plan requires all prospective organizational providers to complete initial
credentialing prior to contracting. This includes verification of specific criteria and site visits
when appropriate. Recredentialing is done at least every three years. Facilities are reviewed by
the Credentials and Quality Committee.

6.11 Credentialing Delegation

The Health Plan has established a delegated credentialing relationship with specific, contracted
organizations. These entities are audited every year with results being submitted to the
Credentials and Quality Committee.

6.12 Disease Management

Disease Management is a population based approach to the clinical and quality management of
identified chronic conditions. This approach identifies individuals with chronic disease, and
through the use of disease-specific interventions, attempts to alter the course of the disease.

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Program components include mailed educational materials, provider education on evidence-
based clinical guidelines, telephonic member education, and care coordination. Disease
Management programs include:
  Rare Diseases
  Congestive Heart Failure
  Coronary Artery Disease
  Chronic Obstructive Pulmonary Disease

6.13 Utilization Management Decision Processes

Utilization management decisions are supported by approved definitions, criteria, and medical
policies. Additionally, board certified specialists are utilized for decision making, in specialized
cases, or in cases where medical appropriateness is unclear. When making a determination of
coverage based on medical necessity, the Health Plan obtains relevant clinical information and
may consult with the treating physician.

6.14 Denial Process

Service denials are issued when requested services are not a covered benefit or do not meet
medical necessity criteria. Licensed clinical staff review all cases where medical criteria is not
met. If a denial decision is made, the decision is communicated to the requesting practitioner.
Denial letters include an explanation or reason for the denial written in lay terms and include
the medical policy criteria used to make the decision. The letter includes the member’s appeal
rights including the right to an expedited appeal.

6.15 Appeal Process

The practitioner or the member may appeal any denied utilization management decision.
Appeals are completed within required timelines. Extensions to this timeline may be necessary
when the case is complex and specialty physician review is necessary. The appeal decision is
communicated to the member, including an explanation of the decision rationale and a
description of the review process.

If the denial is upheld, the decision and the reason for upholding the decision are
communicated to the member and practitioner. The notification also includes information on
how the member can access additional levels of appeal. If the denial is reversed, provision of
the service is arranged in conjunction with the requesting practitioner.

6.16 External Review

The Health Plan notifies commercial members of the right to request an independent, external
binding appeal, if the member is dissatisfied with the grievance committee determination for
denials based on medical necessity. The Health Plan may opt to forward an appeal relating to
medical appropriateness to an external appeal organization at any point in the appeal process,
with the member approval. External review is automatically available to Medicare members
following unfavorable first level appeal decisions and is offered to Medicaid members through
the Fair Hearing process.

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       6.17 Quality Assurance

       Medical management staff support the quality management program through identification of
       potential quality of care issues. Identification of potential quality concerns may be initiated at
       any point in the review process and at any level of review and are referred for investigation and
       follow-up. Conditions or situations that might result in a quality management referral include:
         Requests for repeat procedures due to complications from previous medical care
         Medical injury secondary to the procedure or treatment
         Unexpected readmissions
         Untoward outcomes
         Identified drug mismanagement
         Risk management issues
         Member complaints
         Practitioner/Provider complaints
         Access to care issues

       Quality of service issues are identified from reporting functions, customer and provider
       concerns, and evaluation of processes. A team-centered approach, which mobilizes key
       individuals and departments, is used to resolve and/or implement improvement initiatives and
       follow-up on outcomes.

       6.18 Delegation of Utilization Management Activities

       The Quality and Utilization Management Program is accountable for approval and oversight of
       delegated utilization management activities to ensure compliance with regulatory and accrediting
       requirements. The program policies and program standards must be met by the delegated
       entities’ medical management programs.

       Delegated entities provide the Health Plan with reports on a regular basis. These include denial
       logs and inter-rater reliability audits. Ongoing assessment of delegation includes onsite visits,
       audits, and evaluation of program documents and policies. This process verifies the delegate’s
       ability to administer a Utilization Management Program. Revocation of delegation is
       recommended and approved by the Utilization Management Committee.

7.0 Data Sources and Analysis

Data are used to analyze and measure quality and utilization management activities, trends, variations,
and outcomes. Trends are monitored by the QMM committees and support new or enhanced medical
management programs and quality improvement projects. Compliance with quality and utilization
management directives, including over- and under-utilization, is incorporated into performance
indicators, which are used in the re-credentialing and reappraisal process. These performance indicators
and standards are part of the Quality and Utilization Management Program.

8.0 Quality and Utilization Management Program Evaluation

The Quality and Utilization Management Program is evaluated annually. The evaluation is reviewed by
the Utilization Management Committee with final approval given by the Quality Improvement Team.

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9.0 Confidentiality

All staff involved in quality and utilization management activities are required to maintain
confidentiality. Health Plan employees are oriented to confidentiality policies when first hired. These
are reviewed and signed off on annually. Temporary employees must also review the confidentiality
policy and sign a confidentiality and nondisclosure statement. External practitioners participating in
Health Plan committees or in an advisory role must sign an annual confidentiality and nondisclosure
statement. In addition to the PHS Confidentiality Policy (OR-200), the Health Plan maintains
confidentiality guidelines.

10.0 Conflict of Interest Statement/Ethics and Accountability

Conflict of Interest Statement
Practitioners and staff engaged in the peer review and/or the medical necessity determination process
shall do so without conflict of interest. No practitioner will participate in the review of a case in which
he/she has provided direct care or has a financial interest or relationship.

Ethics and Accountability
  Health Plan Responsibilities According to Ethics and Accountability Guidelines
    The Health Plan has the responsibility to “ensure that clinical criteria take priority over financial
    considerations in member care.” The Health Plan has the responsibility to monitor whether
    providers are inappropriately basing treatment decisions on financial considerations and take
    appropriate action.

  Provider Responsibilities According to Ethics and Accountability Guidelines
    It is the responsibility of the provider to “give priority to clinical and scientific considerations over
    financial considerations.”
    The Health Plan’s compensation agreements for individuals who provide utilization review services
    do not contain incentives, direct or indirect, for those individuals to make inappropriate review

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