Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-58 - MyCare Ohio
Section 5160-58-03.1 - MyCare Ohio plans: primary care and utilization management
Universal Citation: OH Admin Code 5160-58-03.1
Current through all regulations passed and filed through September 16, 2024
(A) A MyCare Ohio plan (MCOP) will ensure each member has a primary care provider (PCP) who will serve as an ongoing source of primary care and assist with care coordination appropriate to the member's needs.
(1)
The MCOP will
ensure PCPs are in compliance with the following triage requirements. Members
with:
(a)
Emergency care needs will be triaged and treated immediately
on presentation at the PCP site;
(b)
Persistent
symptoms will be treated no later than the end of the following working day
after their initial contact with the PCP site; and
(c)
Requests for
routine care will be seen within six weeks.
(2)
PCP care
coordination responsibilities include at a minimum the following:
(a)
Assisting with
coordination of the member's overall care, as appropriate for the
member;
(b)
Providing services which are medically necessary as
described in rule
5160-1-01 of the Administrative
Code;
(c)
Serving as the ongoing source of primary and
preventative care;
(d)
Recommending referrals to specialists, as required;
and
(e)
Triaging members as described in paragraph (A)(1) of
this rule.
(B) The MCOP will have a utilization management (UM) program with clearly defined structures and processes designed to maximize the effectiveness of the care provided to the member. The MCOP will ensure decisions rendered through the UM program are based on medical necessity.
(1)
The UM program, based on written policies and
procedures, will include, at a minimum:
(a)
The information
sources used to make determinations of medical necessity;
(b)
The criteria,
based on sound clinical evidence, to make UM decisions and the specific
procedures for appropriately applying the criteria;
(c)
A specification
that written UM criteria will be made available to both contracting and
non-contracting providers; and
(d)
A description of
how the MCOP will monitor the impact of the UM program to detect and correct
potential under- and over-utilization.
(2)
The MCOP's UM
program will ensure and document the following:
(a)
An annual review
and update of the UM program.
(b)
The involvement
of a designated senior physician in the UM program.
(c)
The use of
appropriate qualified licensed health professionals to assess the clinical
information used to support UM decisions.
(d)
The use of
board-certified consultants to assist in making medical necessity
determinations, as necessary.
(e)
That UM decisions
are consistent with clinical practice guidelines as specified in rule
5160-26-05.1 of the
Administrative Code. The MCOP will not impose conditions on the coverage of a
medically necessary medicaid-covered service unless they are supported by such
clinical practice guidelines.
(f)
The reason for
each denial of a service, based on sound clinical evidence.
(g)
That compensation
by the MCOP to individuals or entities that conduct UM activities does not
offer incentives to deny, limit, or discontinue medically necessary services to
any member.
(h)
Compliance with the Mental Health Parity and Addiction
Equity Act (MHPAEA) requirements outlined in 42 CFR Part 438 Subpart K (October
1, 2021).
(3)
The MCOP will process requests for initial and
continuing authorizations of services from their providers and members. The
MCOP will have written policies and procedures to process initial requests and
continuing authorizations. Upon request, the MCOP's policies and procedures for
initial and continuing authorizations will be made available for review by the
Ohio department of medicaid (ODM). The MCOP's written policies and procedures
for initial and continuing authorizations of services will also be made
available to contracting and non-contracting providers upon request. The MCOP
will ensure and document the following occurs when processing requests for
initial and continuing authorizations of services:
(a)
Consistent
application of review criteria for authorization decisions.
(b)
Consultation with
the requesting provider, when necessary.
(c)
Any decision to
deny a service authorization request or to authorize a service in an amount,
duration, or scope that is less than requested, will be made by a health care
professional who has appropriate clinical expertise in treating the member's
condition or disease.
(d)
That a written notice will be sent to the member and
the requesting provider of any decision to reduce, suspend, terminate, or deny
a service authorization request, or to authorize a service in an amount,
duration, or scope that is less than requested. The notice to the member has to
meet the requirements of division 5101:6 and rule
5160-26-08.4 of the
Administrative Code.
(e)
For standard authorization decisions, the MCOP will
provide notice to the provider and member as expeditiously as the member's
health condition requires but no later than ten calendar days following receipt
of the request for service. If requested by the member, provider, or MCOP,
standard authorization decisions may be extended up to fourteen additional
calendar days. If requested by the MCOP, the MCOP has to submit to ODM for
prior-approval, documentation as to how the extension is in the member's
interest. If ODM approves the MCOP's extension request, the MCOP will give the
member written notice of the reason for the decision to extend the time frame
and inform the member of the right to file a grievance if he or she disagrees
with that decision. The MCOP will carry out its determination as expeditiously
as the member's health condition requires and no later than the date the
extension expires.
(f)
If a provider indicates or the MCOP determines that
following the standard authorization timeframe could seriously jeopardize the
member's life or health or ability to attain, maintain, or regain maximum
function, the MCOP will make an expedited authorization decision and provide
notice of the authorization decision as expeditiously as the member's health
condition requires but no later than forty-eight hours after receipt of the
request for service. If requested by the member or MCOP, expedited
authorization decisions may be extended up to fourteen additional calendar
days. If requested by the MCOP, the MCOP has to submit to ODM for
prior-approval, documentation as to how the extension is in the member's
interest. If ODM approves the MCOP's extension request, the MCOP will give the
member written notice of the reason for the decision to extend the timeframe
and inform the member of the right to file a grievance if he or she disagrees
with that decision. The MCOP will carry out its determination as expeditiously
as the member's health condition requires and no later than the date the
extension expires.
(g)
For prior authorization of covered outpatient drugs as
defined in
42 U.S.C.
1396r-8(k)(2) (as in effect
July 1, 2022), the MCOP has to make a decision within the timeframes specified
in
42
C.F.R. 423.568(b) (October
1, 2021) for standard decisions and
42
C.F.R. 423.572(a) (October
1, 2021) for expedited decisions. If the prior authorization request is for an
emergency situation, a seventy-two hour supply of the covered outpatient drug
that was prescribed must be authorized while the MCOP reviews the prior
authorization request.
(h)
The MCOP will maintain and submit as directed by ODM, a
record of all authorization requests, including standard and expedited
authorization requests and any extensions granted. The MCOP's records will
include member identifying information, service requested, date initial request
received, any extension requests, decision made, date of decision, date of
member notice, and basis for denial, if applicable.
(4)
The MCOP may,
subject to ODM approval, develop other UM programs.
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