Ohio Administrative Code
Title 5160 - Ohio Department of Medicaid
Chapter 5160-59 - OhioRISE
Section 5160-59-03.1 - OhioRISE: utilization management
Universal Citation: OH Admin Code 5160-59-03.1
Current through all regulations passed and filed through December 16, 2024
(A) The Ohio resilience through integrated systems and excellence (OhioRISE) plan 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.
(1)
The
OhioRISE plan has to ensure decisions rendered through the UM program are based
on medical necessity.
(2)
The UM program has to be based on written policies and
procedures that 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 OhioRISE plan will monitor the impact of the UM program to detect and
correct potential under-and over-utilization.
(3)
The OhioRISE
plan's UM program has to 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)
Review and
consideration of the child and family centered care plan;
(e)
The use of
board-certified consultants to assist in making medical necessity
determinations, as necessary;
(f)
That UM decisions
are consistent with clinical practice guidelines as specified in rule
5160-26-05.1 of the
Administrative Code. The OhioRISE plan may not impose conditions around the
coverage of a medically necessary-covered service unless they are supported by
such clinical practice guidelines;
(g)
The reason for
each denial of a service, based on sound clinical evidence;
(h)
That compensation
by the OhioRISE plan to individuals or entities that conduct UM activities does
not offer incentives to deny, limit, or discontinue medically necessary
services to any member; and
(i)
Adherence to the
Mental Health Parity and Addiction Equity Act (MHPAEA) requirements outlined in
42 CFR Part 438 Subpart K (October 1, 2021).
(B) The OhioRISE plan has to process requests for initial and continuing authorizations of services from their providers and members.
(1)
The OhioRISE plan
has to have written policies and procedures to process requests. Upon request,
the OhioRISE plan's policies and procedures have to be made available for
review by the Ohio department of medicaid (ODM).
(2)
The OhioRISE
plan's written policies and procedures for initial and continuing authorization
of services have to also be made available to contracting and noncontracting
providers upon request.
(C) The OhioRISE plan has to ensure and document the following occurs when processing requests for initial and continuing authorizations of services:
(1)
Consistent
application of review criteria for authorization decisions.
(2)
Consultation with
the requesting provider, when necessary.
(3)
Any decision to
deny a service authorization request or to authorize a service in an amount,
duration, or scope that is less than requested has to be made by a health care
professional who has appropriate clinical expertise in treating the member's
condition or disease.
(4)
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.
(5)
For standard authorization decisions, the OhioRISE plan
has to 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 the OhioRISE plan, standard authorization decisions may be
extended up to fourteen additional calendar days. If requested by the OhioRISE
plan, the OhioRISE plan has to submit to ODM for prior-approval, documentation
as to how the extension is in the member's interest. If ODM approves the
OhioRISE plan's extension request, the OhioRISE plan has to 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 the member disagrees with
that decision. The OhioRISE plan has to carry out its determination as
expeditiously as the member's health condition requires and no later than the
date the extension expires.
(6)
If a provider
indicates or the OhioRISE plan 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 OhioRISE plan
has to 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 OhioRISE plan, expedited authorization
decisions may be extended up to fourteen additional calendar days. If requested
by the OhioRISE plan, the OhioRISE plan has to submit to ODM for
prior-approval, documentation as to how the extension is in the member's
interest. If ODM approves the OhioRISE plan's extension request, the OhioRISE
plan has to 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 OhioRISE plan has to carry out its
determination as expeditiously as the member's health condition requires and no
later than the date the extension expires.
(D) The OhioRISE plan has to maintain and submit as directed by ODM a record of all authorization requests, including standard and expedited authorization requests and any extensions granted. The OhioRISE plan's records have to 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.
Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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