QUEST Integration – Utilization Management

Original Effective Date:

08/01/1994

Current Effective Date:

01/01/2015

HMSA’s utilization management (UM) program is a system of integrated processes and tools, including medical policies and payment determination criteria used in precertification, focused medical review, and claims suspend analyses. This system is designed to identify opportunities for improvement in all settings and levels of care, focus review activities, and create interventions that bring measurable results while ensuring quality and value, and maximizing efficiency for members, providers, and HMSA.

In accordance with their participating provider agreements, participating providers agree to comply with HMSA’s UM requirements.

Payments may be reduced or denied if a participating provider fails to satisfy a UM requirement and an HMSA medical director determines that the service does not meet HMSA medical policy or payment determination criteria.

The UM program:

• Promotes evidence-based medicine.
• Differentiates between specific services in terms of use, cost, and risk to recommend appropriate services to monitor or review.
• Recognizes variations in practice patterns and billing and coding histories to recommend appropriate intervention(s).
• Reduces, when possible, physicians’ administrative activities and expense.
• Maximizes return on investment and improves efficiency.
• Provides a continuous feedback loop to monitor and report results.
• Integrates UM with quality improvement, pharmacy management, and other activities including practitioner re-credentialing and provider profiling.

The UM program has no financial incentives for practitioners or care management targets that promote or discourage use of health care services.

Precertification

Precertification prospectively evaluates health plan benefit applicability and health care services for medical appropriateness in the following general categories:

• Services for which aberrant or potentially inappropriate patterns of care exist.
• New technology or new uses of existing technology.
• Services potentially performed for non-covered purposes (e.g., lifestyle enhancement).
• Transplants or other complex treatments that can be triaged to ensure quality and prevent unexpected out-of-pocket expenses for members.
• Level of care business (e.g., Place of Treatment Program).

HMSA precertification staff is available during normal business hours to receive, discuss, or respond to inquiries regarding UM issues.

Physician reviewers are available to discuss or clarify denial cases with the treating or attending practitioners. (The requesting physician will be called back for discussion within three to five business days from the date of the request.)

Providers or members may contact the Precertification Unit.

Staff who answer or return calls identify themselves as HMSA employees and state their name and title.

Calls outside normal business hours are received by a voice mail system and returned by the following business day.

Calls are referred to appropriate staff members who return calls no later than the next business day during normal business hours.

For questions about behavioral health services, providers or members may contact HMSA’s Behavioral Health Services – QUEST Integration (APS Healthcare Inc.).

Focused Medical Review

HMSA’s Focused Medical Review (FMR) process applies review intensities based on variations in practice patterns, adherence to medical policies or evidence-based medicine, or compliance with billing and coding standards.

Clinical reviews may be conducted concurrently and/or retrospectively by nurse reviewers and medical directors and may also result in referrals to Service Coordinators for assessment as needed for potentially catastrophic and/or complex cases.

Below are goals of the FMR process:

• Improve provider compliance to policies and standards.
• Minimize administrative requirements to reduce provider burden and improve provider satisfaction.
• Reduce unnecessary or redundant benefit costs.

Appeals

When precertification requests are denied, the patient and their representative, if one is used, are provided information on how to file an appeal, the types of appeal available, who can request an appeal, what information to include, and what to do if you disagree with an appeal decision. This information is provided via an attachment to the denial notification entitled, “Member Appeal Rights and Process”.

Service Coordination

HMSA’s Service Coordinator services provide HMSA members with coordinated and proactive interdisciplinary point-of-service care while promoting quality, cost-effective health care. Continuity of care is provided through coordination and integration of services by a service coordinator manager who manages, directs, and assesses the potential effects of services to promote a continuum of care for each member served.

Revision History