Utilization Management Program Description (UM program)
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Defines the structure, staffing, clinical review criteria, and processes of Alacura's utilization management program as applied to members of Blue Cross and Blue Shield of Montana for specified commercial and individual products.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Medical necessity and review criteria
Covered when clinical review using specified criteria supports medical necessity and plan terms:
Preservice prior authorizations confer appeal rights; recommended clinical review is voluntary and processed similarly.
Authorization and review decision logic
Coverage and authorization decisions are made using the following sources and escalation logic.
Clinical reviewers may approve requests that meet these criteria.
Absolute contract exclusions are not processed further.
Provider should proceed to emergency care without prior authorization.
Utilization review criteria and reviewer qualifications
Coverage and utilization review determinations use established clinical criteria and licensed dental consultant review.
Entities delegated BCBSMT business must use the same criteria.
Recommended clinical review
Recommended clinical review process for some dental services
Providers should submit detailed supporting documentation (treatment plan, functional aspects, projected outcome, study models/photographs/x-rays, and appropriate CDT codes) when requested.
Services or determinations that fall outside a member's coverage eligibility at the time of service, or that are explicitly excluded by the member's plan terms, are not covered. The UM program focuses its reviews on determining whether requested services fall within the benefits described in the member's evidence of coverage and applicable plan documents, and will deny coverage for services outside those terms.
Absolute contract exclusions are handled as exclusions and are not advanced through physician or behavioral health reviewer workflows. Requests identified as absolute contract exclusions are not processed further for clinical review and are communicated to the member and provider as an exclusion under the plan.
A utilization review determination may conclude that a service is not a covered service or is subject to an exclusion and/or limitation as defined by the member's evidence of coverage. When a request is escalated for clinical review, adverse determinations (denials, reductions, or terminations) are made only by appropriately credentialed clinicians and are communicated in writing to the member (or authorized representative) and the requesting provider.
Services that are primarily for convenience, are not in accordance with generally accepted standards of practice, or are more costly than an equivalent alternative that is at least as likely to produce equivalent results are considered not medically necessary and are not covered.
During retrospective (post-service) review, UM clinicians evaluate clinical documentation to determine whether the service was medically necessary, not experimental or investigational, and covered under the member's benefit plan. If documentation does not support medical necessity, the service may be denied or payment reduced based on the retrospective determination.
A denial or rejection of a prior authorization or payment request frequently indicates that the service is not a covered service or is subject to an exclusion or limitation under the member's contract rather than an affirmative clinical finding that the service is medically required. All adverse determinations include written notice and appeal rights as required by policy.
Coding and Documentation Codes
| Current Dental Terminology codes | Appropriate CDT codes required for documentation and recommended clinical review |
Provider Requirements, Prior Authorization, and Documentation
Prior authorization is required for certain services
Certain services require prior authorization as a preservice review that conditions receipt of benefits and includes appeal rights; prior authorizations and recommended clinical reviews are processed the same way but prior authorization is required for specific services.
- Prior authorization is a preservice review.
- Prior authorization reviews include appeal rights.
- Prior authorization is required for certain services; recommended clinical review is voluntary.
Submit required prior authorizations via web platform or UM review
Prior authorization is required for select inpatient admissions and outpatient services submitted through the automated web platform or reviewed via the utilization review process; emergency screening and stabilization do not require prior authorization.
- Requests for elective or emergent inpatient admissions, select outpatient services, coordinated home care/home infusion and transplants not completed via the automated web platform are reviewed through utilization review.
- The automated web platform accepts submissions 24/7 from physicians or facility personnel (including diagnosis/procedure codes and medical records).
- Emergency screening and stabilization do not require prior authorization.
Dentists: recommended clinical review for some services
Although dentists are not required to submit claims for prior authorization, recommended clinical review is advised for some dental services to help avoid unexpected expenses and to determine coverage for medically necessary services.
- Utilization review for dental services occurs both prospectively and retrospectively.
- Recommended clinical review determines coverage; if not obtained, retrospective review will assess medical necessity and benefit applicability.
Use ASAM, MCG and medical policy to determine appropriateness
UM clinicians apply ASAM Criteria, MCG care guidelines and the payer's medical policy to determine medical necessity, appropriate level and site of care, length of stay, and duration of service; requests that do not meet these criteria are escalated to physician reviewers.
- ASAM and MCG criteria and medical policy are used to evaluate appropriateness of treatment setting, length of stay, and duration of service.
- UM clinicians may approve requests that meet established criteria; non-conforming requests are referred to physician reviewers.
Verify member eligibility and match requested services to authorization
Providers must verify member eligibility and ensure that the services requested match the prior authorization or recommended clinical review request; benefits are conditioned on member eligibility, any changes in condition, rendered services matching the request, and the member's plan terms.
- Confirm member coverage eligibility at time of service before relying on prior authorization.
- Ensure the actual services rendered match what was authorized or reviewed; differences can affect benefit payment.
Submit complete clinical documentation from reliable sources
UM clinicians document and accept clinical information from multiple reliable sources (verbal information from treating clinicians, medical office/facility personnel, and provider medical records); physicians or facility personnel may submit diagnosis and procedure codes and medical records via the automated web platform for prior authorization requests.
- UM staff use verbal and medical record information to determine whether established criteria are met.
- Providers may input diagnosis/procedure codes and upload medical records through the automated web platform.
Provide detailed documentation for recommended clinical review
For recommended clinical review, providers must supply pertinent documentation including an explanation of proposed services, functional aspects, projected outcome, treatment plan, supporting materials (study models, photos, x-rays), and appropriate Current Dental Terminology codes.
- Include treatment plan and projected outcome.
- Provide supporting materials such as study models, photographs and x-rays.
- List appropriate Current Dental Terminology (CDT) codes.
Prior authorization reviews can lead to denials and affect benefits
Because prior authorization conditions receipt of benefits upon a preservice review, prior authorization reviews may result in denials; adverse determinations include appeal rights and are communicated in writing.
- Prior authorization reviews include appeal rights.
- Neither prior authorization nor recommended clinical review guarantee benefits or payments.
Nonconforming requests may be denied or escalated to physician review
Requests that do not meet ASAM Criteria, MCG care guidelines, medical policy, or that appear to be potential contract exclusions are referred to physician reviewers and may result in adverse determinations (denial, reduction, or termination) communicated in writing.
- Non-conforming requests are escalated to physician or behavioral health physician reviewers (or behavioral health psychologists when applicable).
- Adverse determinations are communicated in writing and may be appealed.
Denials and recommended review outcomes are adverse determinations with appeal rights
A decision to deny or partially deny a claim payment is an adverse benefit determination; failure to obtain a recommended clinical review may result in retrospective review and possible denial or reduced benefit, and adverse determinations are subject to appeal procedures.
- Adverse determinations (denials/partial denials) are adverse benefit determinations.
- If recommended clinical review is not obtained, a retrospective review determines medical necessity and benefit applicability.
Program Background and Scope
The UM program uses nationally recognized, evidence-based clinical criteria to evaluate medical necessity and appropriateness of care. For behavioral health and substance-related disorders the program applies the ASAM Criteria, and for medical/surgical level-of-care and utilization decisions it uses MCG care guidelines, together with the payer's medical policy. These sources guide preservice, concurrent and retrospective reviews and are applied annually as part of program oversight.
Definitions
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