Utilization Management Program Description
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Defines the structure, processes, authority, and goals of Carolina Complete Health's Utilization Management (UM) program, applying to UM, Quality, Compliance, Pharmacy, and Member Services and affecting all eligible members across product types and care settings.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
Program Coverage and Medical Necessity Governance
Covered when program governance and medical necessity processes are followed
UM Program Coverage Requirements
- Program Processes: UM processes including prior authorization/precertification, concurrent review, ambulatory review, retrospective review, care management and disease management are used to determine medical necessity and coverage.
UM program provides 24-hour nurse triage and integrates pharmacy/P&T and behavioral health oversight.
Medical Necessity and UM Process
Covered when administrative and clinical processes are followed and medical necessity is established:
Includes emergent/urgent inpatient services and obstetrical deliveries
Care Managers and administrative staff must refer adverse determinations to Medical Director
Levels of Review and Decision Criteria
UM determinations follow a two-level review process and use nationally recognized criteria; decisions consider individual patient needs and local delivery system.
Clinical Criteria Sources
Sources and tools used to determine medical necessity for specific service types.
Concurrent Review
Concurrent review for inpatient hospitalization is conducted throughout the stay with each hospital day approved based on review of condition and medical necessity.
Can occur onsite or telephonic and referrals to Medical Director occur when medical necessity cannot be determined.
Retrospective Review
Retrospective review applies to services already rendered without prior authorization.
Applies to participating or non-participating practitioners when no concurrent review opportunity existed.
Emergency Services
Emergency services are covered without prior authorization and until the member is stabilized.
Plan may not deny coverage for emergency services due to late notification except as related to claim filing timeframes.
Appeals
Appeals process and timelines for adverse determinations.
Punitive action not taken against practitioners who request expedited resolution.
Medical peer of same or similar specialty, not involved in original determination, evaluates adverse appeal decisions.
Emergency Services Coverage
Emergency services are covered when the following condition is met:
Coverage includes screening exam and services needed to evaluate or stabilize; covered until stabilized; non-network practitioners covered for emergency services.
Pharmaceutical Management and Prior Authorization
Pharmacy coverage and PA governance:
PA process follows state/federal requirements and NCQA standards.
Behavioral Health Levels of Care
Behavioral health services are provided across defined levels of care; coverage varies by Plan contract and may have associated limitations:
Coverage availability and limitations vary by contract; treatment plans should be individualized and updated per level-specific requirements.
Treatment plan must set discharge criteria and barriers to discharge.
Specific treatment goal to return member to a lesser level of care.
Program must provide integrated services addressing mental health/substance abuse needs.
Aims to reduce symptom severity and improve functioning.
Disease and Care Management
Disease and Care Management:
Programs require extended interactions with trained nursing professionals.
Care Management Program described in separate program description.
This policy references compliance with applicable Department and DHHS requirements. The Plan's Utilization Management Program Description is maintained by Population Health and Clinical Operations and is reviewed at least annually to ensure consistency with regulatory and accrediting guidelines, including applicable NC DHHS Clinical Coverage Policies and other Department policies that may identify specific exclusions or requirements.
Staff compensation and incentive structures are managed to prevent financial influence on UM decisions. Compensation or incentives based on the amount or volume of adverse determinations, reductions in length of stay, or frequency of contacts that could encourage underutilization are prohibited. All staff performing UM reviews sign an annual affirmative statement regarding compensation.
Prior authorization is required only for services on the Plan's prior authorization list. Prior authorization is never required for emergency services or urgent care services. Emergency department and related emergency services are available 24/7 and are covered based on the presenting symptom severity and prudent layperson standard until the member is stabilized.
Network practitioners must avoid referral arrangements that create conflicts of interest. Specifically, practitioners are prohibited from referring designated health services to entities with which they or family members have a financial relationship. The Plan will authorize out-of-network services when in-network services of appropriate specialty or expertise are unavailable, consistent with continuity of care and access standards.
An emergency medical condition is defined by the presence of acute symptoms of sufficient severity that a prudent layperson could reasonably expect lack of immediate attention to result in serious jeopardy, serious impairment of bodily functions, or dysfunction of any bodily organ or part. This definition is not based on lists of diagnoses or symptoms.
The Plan may delegate UM activities to qualified organizations, but delegation is conditional. A pre-delegation review and execution of a delegation agreement are required, the delegate must conform to the Plan's UM standards and reporting requirements, and the Plan retains accountability for delegated functions through ongoing oversight and annual review.
Cases that do not meet medical necessity criteria are escalated for clinician review. Care Managers refer requests that fail standard UM criteria to the Medical Director or other appropriately licensed clinician; such reviews may result in a denial after appropriate clinical review and physician sign-off.
Requests that do not meet the Plan's standard UM criteria and lack medical necessity are subject to adverse determinations. These cases are referred to the Medical Director or an appropriately licensed practitioner for final medical necessity review and determination.
After Level II review by an appropriately licensed practitioner, outcomes may include authorization in a lesser scope, duration, or amount, or full denial. Level II reviewers, including the Medical Director when appropriate, may authorize fewer services or deny the request if medical necessity criteria are not met.
Denials (adverse determinations) may be issued when requested services lack medical necessity or fall outside benefit limitations. The Medical Director may propose alternatives; if the requester does not accept an approved alternative, the originally requested service may be denied, and written notification with rationale and appeal rights is provided.
This inventory item is a placeholder with no substantive content in the current policy section.
Provider Responsibilities and Authorization Procedures
Plan maintains list of services requiring prior authorization
The UM Program maintains and periodically updates a list of procedures and services that require prior authorization or precertification; providers must consult the Plan's prior authorization list before scheduling or rendering non-emergent services.
- The MMC develops and annually reviews/approves the list of services requiring prior authorization (MMC scope).
- Prior authorization is required only for services where review can favorably influence quality or financial impact (e.g., non-emergent inpatient admissions, out-of-network services, certain outpatient and ancillary services, specialty injectables).
Prior authorization required for listed services; PBM role
Services that appear on the Plan's prior authorization list require a formal PA request; when pharmacy PA applies, the PBM administers the PA process per state law and PBM criteria with Plan oversight.
- PBM performs pharmacy prior authorization where permitted and the Plan Pharmacy Manager reviews pharmacy PA requests that do not meet criteria.
- PA decisions follow criteria developed and approved by the Plan P&T Committees in conjunction with the PBM.
Request PA prior to rendering listed services
Providers must submit a formal prior authorization request to the Plan before rendering services listed on the Plan's PA list; the request will be screened for eligibility, benefits, and medical necessity and only minimally necessary clinical information will be requested.
- Requests are screened for eligibility and benefit coverage and assessed for medical necessity and appropriateness.
- Only minimally necessary clinical information will be requested to certify the service (see Clinical Information examples).
PA required for specialty injectables; retrospective review process
Prior authorization is required for specialty injectable medications per established clinical criteria; retrospective authorization requests are reviewed by the Director of Population Health and Clinical Operations (or designee) and may be approved if documentation satisfies administrative waiver and medical necessity.
- Specialty injectable PA requests that do not meet criteria are referred to the Plan Pharmacist and Medical Director as needed.
- Retrospective requests are reviewed using the standard medical necessity process; questionable cases are referred for Medical Director review.
Pharmacy prior authorization for selected medications (PBM-administered)
Pharmacy prior authorization is required for selected high‑risk, high‑cost, or high‑abuse‑potential medications; the PBM administers the PA process in accordance with applicable state and federal requirements and Plan P&T criteria.
- PA criteria for drugs are developed, reviewed, and approved by the Plan P&T Committees in conjunction with the PBM.
- The Plan PDL is maintained by the corporate and Plan P&T Committees and is available on the Plan website or upon request.
Obtain certification/PA after emergency stabilization
Once a member's emergency medical condition is stabilized, certification or prior authorization is required for hospital admission or follow‑up care; failure to obtain required post‑stabilization authorization may lead to denial of coverage for those non‑emergent services.
- Emergency services are covered without prior authorization until stabilization; after stabilization, obtain certification/PA for admission or follow-up.
- Lack of prior authorization for subsequent non‑emergent care may affect coverage for those services.
Delegates must adhere to Plan UM standards and reporting
Entities delegated to perform UM activities must conform to the Plan's UM standards, meet required timeframes (including NC.UM.05), provide a written UM Program Description/Plan for annual review, and submit required utilization and quality reports.
- A pre‑delegation review and executed delegation agreement are required; the agreement specifies reporting requirements and performance standards.
- Delegates must submit monthly utilization summaries, high cost days, and QA/IM issues as applicable, and are subject to ongoing oversight and annual review.
Pharmacy and P&T oversight integrated with UM
A Plan pharmacist and the P&T process are integrated with UM operations; the Pharmacy Manager reviews PA requests that do not meet criteria and collaborates with the Medical Director as needed.
- Pharmacy oversight includes monitoring pharmacy utilization and reporting findings to the MMC and QIC.
- Pharmacist involvement supports clinical review and PA decision-making.
Apply medical necessity criteria and LTSS assessments for authorization
Authorization decisions are made by applying established medical necessity criteria and, where applicable, LTSS assessments; requests that do not meet standard UM criteria are referred to the Medical Director for review.
- UM criteria are nationally recognized, evidence‑based, and reviewed at least annually.
- LTSS approvals must be supported by an assessment of needs.
Step therapy not specified here
Step therapy requirements are not specified in this section of the UM Program Description.
- Refer to pharmacy-specific policies or the PBM for any step therapy protocols.
Use Plan Preferred Drug List and preferred agents
The Plan maintains a Preferred Drug List (PDL) developed from the corporate PDL; the Plan P&T Committee determines inclusion of drugs and the PDL should be used to identify preferred agents.
- The corporate PDL is developed by the corporate P&T Committee; the Plan PDL is available on the Plan website or in hard copy upon request.
- The Pharmacy Manager is the point of contact for practitioners regarding PDL concerns.
Maintain confidentiality and secure UM documentation
All medical and UM documentation must be secured, marked confidential, accessible only to essential personnel, and staff and UM committee members must sign confidentiality statements/waivers.
- Medical information sent by mail or fax must be clearly marked 'personal and confidential'.
- Electronic medical information is protected by user access passwords and other security configurations; confidential information is destroyed when no longer needed.
Maintain MMC minutes and complete the UM process upon notification
The MMC maintains meeting minutes and UM activity reports; the UM process begins with receipt of an authorization request and is complete when the requesting practitioner and member are notified of the determination.
- MMC meets at least four times per year and VPMM maintains detailed records of MMC minutes and UM activity.
- UM process components include triage, referrals, PA, concurrent and retrospective review, discharge planning, and care coordination.
Submit minimally necessary supporting clinical information with PA requests
For PA requests, submit only the minimally necessary clinical information to certify the admission, procedure, length of stay, or frequency/duration of services; supporting documentation examples are listed in the policy.
- Acceptable documentation includes office/hospital records, history, exam notes, diagnostic results, treatment plans/progress notes, consults, operative reports, LOCUS/CALOCUS when applicable, and other pertinent items.
- Clinical rationale and prior therapy information should be included for pharmacy PA requests.
Provide medical records only when requested and only pertinent sections
Medical records will be requested only when necessary to certify medical necessity during prospective or concurrent review or to investigate complaints/appeals or quality issues; only pertinent sections of the record are required.
- Records are not routinely requested for all patients; requests focus on information needed to complete the review.
- Providers are not typically reimbursed for costs of copying/transmitting records unless modified by law.
Document presenting symptoms and screening exam for emergency services
For emergency services, document the member's presenting symptoms and the medical screening examination that demonstrates an emergency medical condition; although the Plan may set notification timelines, failure to notify alone will not result in denial of emergency services coverage except as related to claim filing timeframes.
- Emergency services are covered based on the prudent layperson standard and remain covered until the member is stabilized.
- If a Plan practitioner instructs the member to seek emergency care, the screening exam and necessary emergency services are covered regardless of the prudent layperson standard.
Provide clinical rationale and prior therapy data with pharmacy PA requests
Pharmacy PA decisions are based on criteria developed and reviewed by the Plan P&T Committee and PBM using clinical evidence; include supporting clinical rationale and prior therapy information with pharmacy PA requests.
- PBM-administered PA follows state/federal requirements and NCQA standards.
- Include prior therapy history and clinical rationale to support approval of requested medication.
Delegates must supply UM program description and utilization reports
Delegates must provide a written UM Program Description/Plan for annual review and approval by the Plan and must submit utilization reports (monthly summaries, high cost days, QA/IM issues) as required.
- Pre‑delegation review and an executed delegation agreement are required to clarify responsibilities and reporting.
- The Plan retains accountability and monitors delegate performance through routine reporting and annual evaluations.
Denials possible when services fail medical necessity and require physician review
Services that do not meet medical necessity criteria may be denied after appropriate review and physician (Medical Director) sign‑off; practitioners are provided opportunities for peer‑to‑peer discussion and written notification of adverse determinations.
- Denials are communicated in writing with case‑specific rationale, criteria used, and appeal instructions; verbal notification and peer discussion opportunities are provided when applicable.
- Medical Director may propose alternatives; if requester does not accept the alternative, the original request may be denied.
Medical necessity denials reviewed by physician/licensed professional
All medical‑necessity based denials are reviewed by a physician or appropriately licensed health care professional; Care Managers and administrative staff must refer potential adverse determinations to the Medical Director and may not make final clinical denials.
- Personnel performing utilization review are appropriately qualified, trained, and licensed.
- Care Managers are prohibited from making adverse medical necessity determinations and must refer cases failing criteria to the Medical Director.
Risk of denial or reduction after Level II review
If a request fails Level I criteria, a Level II Review by an appropriately licensed practitioner may authorize fewer services or deny the request; the Medical Director reviews potential denials for medical appropriateness.
- Level II reviews are conducted by practitioners with appropriate licensure and specialty-specific reviewers when applicable.
- Level II may authorize less than requested or deny services when criteria are not met; Medical Director involvement is required for potential denials.
Denial possible if Medical Director finds service not medically necessary or alternatives rejected
If the Medical Director determines the requested service is not medically necessary or the requester does not accept an offered alternative, the service may be denied based on medical necessity or benefit limits.
- Denial notices include specific criteria and rationale, and outline appeal rights and timelines per NC.UM.05.
- Practitioners may discuss denials with the Plan Medical Director or appropriate practitioner reviewer via peer‑to‑peer contact.
Obtain post‑stabilization certification/PA or risk denial for subsequent care
Failure to obtain required certification for admission or prior authorization for follow‑up care after emergency stabilization can lead to denial of coverage for those subsequent non‑emergent services.
- Emergency services and screening exams remain covered until stabilization; post‑stabilization care requires certification/PA.
- The Plan may not deny emergency care coverage solely for late notification except when related to claim filing timeframes.
Pharmacy PA required for select medications; lack of PA may cause non‑coverage
Pharmacy prior authorization is required for selected high‑risk, high‑cost, or high‑abuse potential medications per PBM criteria; failure to obtain required PA may result in non‑coverage of the medication claim.
- PBM‑administered PA criteria are consistent with clinical literature and P&T Committee decisions.
- The Plan Pharmacy Manager reviews PA requests that do not meet criteria and may consult the Medical Director.
Delegate nonconformance may trigger oversight, corrective action, or denial of delegated activities
Failure of a delegated entity to conform to the Plan's UM standards, including timeliness requirements in NC.UM.05, may result in Plan oversight actions, corrective action, and potential denial of delegated activities.
- The Plan retains accountability and conducts ongoing oversight, routine reporting of key metrics, and annual evaluations of delegates.
- Corrective action or oversight may be initiated for nonconformance with Plan standards or reporting obligations.
Key Definitions
Program Background
The Utilization Management Program ensures that services are covered only when they are covered benefits, medically necessary, appropriate to the patient’s condition, rendered in the appropriate setting, and meet professionally recognized standards of care. The program encompasses prior authorization, concurrent and retrospective review, care management, disease management, and integrates pharmacy and behavioral health oversight to promote consistent, impartial utilization decisions and appropriate resource use.
Policy Revision History
Policy became effective on July 1, 2021 as the Carolina Complete Health Utilization Management Program Description (NC.UM.01).
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