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Care Management/ Utilization Management Overview of Care Management/Utilization Management.

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Presentation on theme: "Care Management/ Utilization Management Overview of Care Management/Utilization Management."— Presentation transcript:

1 Care Management/ Utilization Management Overview of Care Management/Utilization Management

2 Care 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 providers Certifying service requests or recommending other supportive services.

3 Care 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.

4 Care Management/ Utilization Management Clinical Reviewers utilize the State Funded Service Definitions for State funded(IPRS) service requests. State funded Service Definitions: /index.htm.

5 Care Management/ Utilization Management Clinical Reviewers utilize the Medicaid Clinical Coverage Policy when reviewing Medicaid covered services. Clinical Coverage Policy –Enhanced Services: –Outpatient Services: –Inpatient Services: –Residential Services: –Psychiatric Residential Treatment Facility Services(PRTF): –Innovations:

6 Care 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.

7 Care 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.

8 Care 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.

9 Care Management/ Utilization Management If you need assistance with submitting a SAR, you can contact the or you can access Alpha MCS University for assistance.

10 Care Management/ Utilization Management Sandhills Center Utilization Management Department toll free number:


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