Presentation on theme: "Care Management/ Utilization Management"— Presentation transcript:
1Care Management/ Utilization Management Overview of Care Management/Utilization Management
2Care Management/ Utilization Management Utilization Management is the means by which Sandhills Center monitors the appropriateness, amount and duration of care by:Reviewing requests for covered services submitted by member providersCertifying service requests or recommending other supportive services.
3Care Management/ Utilization Management Medical Director provides clinical oversight of the Department.Department is comprised of Master level licensed clinicians who review service request for clinical appropriateness.
4Care Management/ Utilization Management Clinical Reviewers utilize the State Funded Service Definitions for State funded(IPRS) service requests.State funded Service Definitions:
6Care Management/ Utilization Management If the Care Manager is unable to approve the service request a peer review is completed.Peer Reviews are completed by physicians contracted with the SHC.Peer Review is intended to give the provider an opportunity to provide additional information regarding medical necessity.
7Care Management/ Utilization Management Once peer review is completed the physician can recommend approval of the service request or denial of the service request.If the recommendation is approval, the authorization is immediately approved in the system.If the recommendation is denial, the member is notified of their appeal rights.
8Care Management/ Utilization Management Members can appeal the decision to the SHC. This is considered a reconsideration review.If the decision is overturned, the authorization is immediately approved in the system.If the decision is upheld, the member is notified of their appeal rights to the State or OAH.
9Care Management/ Utilization Management If you need assistance with submitting a SAR, you can contact the or you can access Alpha MCS University for assistance.
10Care Management/ Utilization Management Sandhills Center Utilization Management Department toll free number: