Missouri Code of State Regulations
Title 22 - MISSOURI CONSOLIDATED HEALTH CARE PLAN
Division 10 - Health Care Plan
Chapter 3 - Public Entity Membership
Section 22 CSR 10-3.045 - Plan Utilization Review Policy

(A) Preauthorization-The claims administrator must authorize some services in advance. Preauthorization is to determine if the procedure or treatment is medically necessary. The claims administrator will determine what procedures or treatments are subject to preau-thorization. Without preauthorization, any claim that requires preau-thorization will be denied for payment. Members who have another primary carrier, or who are enrolled in the Medicare Advantage Plan are not subject to this provision except for those services that are not covered by the other primary carrier, but are otherwise subject to preauthorization under this rule. Preauthorizations found to have a material misrepresentation or intentional or negligent omission about the person's health condition or the cause of the condition may be rescinded.

(B) Concurrent Review-The claims administrator will monitor the medical necessity of an inpatient admission to certify the necessity of the continued stay in the hospital. Members who have another primary carrier, including Medicare, are not subject to this provision;

(C) Retrospective Review-Reviews to determine coverage after services have been provided to a member. The retrospective review is not limited to an evaluation of medical necessity, reimbursement levels, accuracy and adequacy of documentation or coding, or settling of payment. The claim administrator shall have the authority to correct payment errors when identified under retrospective review;

(D) Pre-determination-Determination of coverage by the claims administrator prior to services being provided. A provider may voluntarily request a pre-determination. A pre-determination informs the provider of whether, and under which circumstances, a procedure or service is generally a covered benefit under the plan. A pre-deter-mination that a procedure or service may be covered under the plan does not guarantee payment; and

(E) Case Management-A voluntary process to assess, coordinate, and evaluate options and services of members with catastrophic and complex illnesses. A case manager will help members understand what to expect during the course of treatment, help establish collaborative goals, complete assessments to determine needs, interface with providers, and negotiate care. Members are identified for case management through claim information, length of hospital stay, or by referral. The case manager will dismiss the member from case management once the case manager determines that objectives have been met.