RetiredCareSourcePolicy N/A

Policy Development Process - Arkansas PASSE

Governs CareSource's standardized process for developing, approving, and publishing administrative and clinical policies for the Arkansas PASSE program; affects policy writers, business owners, subject matter experts, configuration/coding teams, utilization management, CPGC, external reviewers, and state approvers.

Policy Summary

PayerCareSource

PolicyPolicy Development Process - Arkansas PASSE

Policy CodePolicy N/A

Change TypeClarified / Revised (non-material)

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionIf codes are applicable, the multidisciplinary team reviews codes and may send them to analytics for financial, claims, or usage data as part of policy development.

SourceLink

POLICY UPDATE CHANGES

Date Archived indicates the policy is no longer active and has been archived.

Definitions and resources used for research were updated during prior revisions.

Arkansas PASSEProgram

PolicyTechSystem

CPGCApprover

MHPAEAParity

Policy Development Lifecycle & Criteria

Policy development lifecycle

Policy development covered when ALL of the following steps and roles are completed:

ALL of the following

ALL of the following
- Business owner enters policy intake into PolicyTech to start the policy development process
  Initiates policy lifecycle via PolicyTech
ALL of the following
- Collaboration between policy writer, business owner, member benefits coder, member benefits analyst, configuration, and an appropriate business owner/SME or medical director to determine intent, need, and priority
ALL of the following

Policy Summary

PayerCareSource

PolicyPolicy Development Process - Arkansas PASSE

Policy CodePolicy N/A

Change TypeClarified / Revised (non-material)

Effective DateJan 1, 2023

Next Review DateN/A

Key ActionIf codes are applicable, the multidisciplinary team reviews codes and may send them to analytics for financial, claims, or usage data as part of policy development.

SourceLink

On This Page

Code Review and Analytics

Code review processmixed

No codes listed

Analytics trigger

Trigger conditionManagement may request that codes be sent to analytics when additional data (financial, claims, or usage) is needed to inform policy development

Responsible partiesMultidisciplinary team reviews codes and configuration to determine analytic needs (policy writer, business owner, coder, analyst, configuration, SME/medical director)

Data types requestedFinancial data, claims data, and member usage of benefits

Decision pointManagement determines whether analytics review is required after multidisciplinary review

PurposeProvide the policy team with additional evidence to support policy drafting, revision, or configuration decisions

Provider and Operational Actions

Note

Multidisciplinary code review with possible analytics referral

If billing or configuration codes are relevant to a policy request, a multidisciplinary team will review those codes and management may refer the codes to analytics for additional data (for example, financial data, claims, or usage of benefits) to inform policy development.

Collaboration includes policy writer, business owner, coder, analyst, configuration staff, SMEs, and medical director when applicable.
Management decides whether to send codes to analytics to obtain financial/claims/usage data to support policy decisions.

Roles, Systems, and Regulatory Definitions

Business Owner

RoleIdentifies gaps in information or benefits and recommends or requests topics for policy research

ResponsibilitiesSupports development of policies by initiating policy intake and collaborating with policy writers and SMEs

Interaction with systemsEnters policy intake into PolicyTech to start the policy development process

StakeholderActs as the business liaison for policy teams and subject matter experts

ScopeMay request research on medical necessity criteria, reimbursement information, or administrative conditions

CPGC (Clinical Policy Governance Committee)

DefinitionOfficial governing body comprised of medical and behavioral health subject matter experts charged with approval of new or revised clinical policies relating to medical necessity determinations

Primary responsibilitiesDetermine whether proposed clinical policies are clearly defined, clinically evidence-based, ensure member safety and quality of care, and articulate business value

CompositionMedical and behavioral health subject matter experts, among others

Approval scopeApproves clinical policies after review and as part of the PolicyTech workflow

PolicyTech

Tool descriptionPolicy and procedure lifecycle management software for policy development and revision

Key featuresWorkflow automation, document creation and review, remote access, versioning, audit-ready reporting, and employee assessments

Use in processUsed to enter policy intake, manage development, revisions, approvals, and finalization

PurposeCentralizes and simplifies policy and procedure workflows

MHPAEA

Regulatory requirementMental Health Parity and Addiction Equity Act (MHPAEA) requires that behavioral health coverage not be subject to limitations that are less favorable or more restrictive than medical/surgical coverage

Application in processPolicy development ensures parity among medical/surgical and behavioral health policies per MHPAEA

Reference in workflowParity considerations are included during research and policy drafting steps

Medical/Clinical Policies

DefinitionPolicies written with medical criteria, including current evidence-based research, best practices, and studies that determine what a member must meet for a provider to deliver a service

ContentInclude medical necessity determinations, evidence base, and standard of care guidelines

Approval pathwayRequire review and approval by subject matter experts, CPGC, and possibly external medical reviewers and state approvers

PurposeEstablish member requirements for service delivery and ensure clinical quality and safety