Utilization Management and Service Authorization

Prepared by: Care Coordination Department 2021 References: z Centers for Medicare and Medicaid Services (CMS) z Code of Federal Regulations (CFR) z Oregon Health Authority (OHA) z National Committee for Quality Assurance (NCQA) z MCG Health CareWebQI z Samaritan Health Plans Care Coordination Department approved policies z Samaritan Advantage Health Plan HMO Approved Special Needs Plan Model of Care z SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach Table of contents

Utilization Management and Service Authorization ...... 1

Program overview ...... 2 Education and support ...... 2 Prior authorization requirements ...... 2 Prior authorization list ...... 3 Authorization specialist review ...... 4 Clinical review ...... 4 Service types ...... 4 Review types ...... 6 Utilization management criteria ...... 6 Evidence-based criteria ...... 6 Criteria examples ...... 7 Request types ...... 7 Notification process ...... 8 Denials / appeals ...... 8 Confidentiality ...... 9 Financial incentives ...... 9

Quality and performance improvement ...... 10 Inter-Rater Reliability ...... 10

IHN-CCO prior authorization list ...... 10

IHN-CCO Care Coordination policies ...... 11 CSD-CC-UM-02 IHN-CCO Authorization Request Policy - SHP ...... 11 CSD-CC-UM-21-IHN-CCO Criteria for Utilization Management Decision Making Policy - SHP ...... 19

Online prior authorization instructions ...... 23 Program overview

Utilization management (UM) is integrated within the Care Coordination care management program. The medical director and Care Coordination director oversee the program operations. Utilization review is conducted according to department policies, procedures and clinical criteria. Benefits and clinical criteria are reviewed. Decisions and notifications must adhere to time frames, policies and plan documents. Prospective, concurrent and retrospective reviews are performed to provide a basis for decision-making. UM decisions are made by qualified, licensed health care professionals who have the knowledge and skills to assess clinical information and to evaluate working diagnoses and proposed treatment plans. Care Coordination is supported by board-certified UM physician reviewers and behavioral health physicians and doctoral-level practitioners who hold a current license to practice without restrictions. These licensed providers oversee UM decisions to ensure consistent and appropriate medical-necessity determinations. Inter-rater reliability reviews are conducted to ensure consistent application of the utilization criteria. The Care Coordination Department at InterCommunity Health Network Coordinated Care Organization (IHN-CCO) utilizes the Cognizant software program, Facets and Clinical Care Advance (CCA). Health plan activities related to members and providers, including authorizations, claims, customer services, appeals, quality and case management, are documented in the systems. Clinical and supporting documentation submitted to Samaritan Health Plans (SHP) is electronically stored within the CCA system. Monitoring for over-utilization and underutilization occurs through utilization and case management reports as well as clinical performance measures, including the Healthcare Effectiveness Data and Information Set (HEDIS). Race, ethnic, cultural and linguistic disparities are used to identify actions for improvement. All sources of member satisfaction surveys, complaints, appeals and grievances are reviewed to identify potential areas of concern. Practitioner medical, pharmacy and utilization profiles are also reviewed.

Education and support IHN-CCO provides a Health Insurance Portability and Accountability Act (HIPAA)-compliant, internet-based portal, called Provider Connect. This is accessible via OneHealthPort and allows providers easy access to real- time authorization information, submission, eligibility and claims. Provider education is accomplished through Provider Connect, special trainings, annual updates and seminars or through news bulletins or clinical education provided by the chief medical officer, Provider Services Department and/or Quality Department. Members may receive education about benefits and care management through welcome letters, periodic newsletters, quality initiatives or projects or individual communication through the efforts of Care Coordination staff.

Prior authorization requirements Decisions regarding what services should require prior authorization are made to target services that are high risk (of complications or side effects), frequently overused (by providers) and high cost (to members and the health plan). Services that are low risk, low cost and not overused by providers are generally not targeted to require prior authorization.

IHN-CCO Utilization Management and Service Authorization Handbook 2 The availability of a nationally recognized, evidence-based guideline (from organizations like MCG Health or the Center for Medicare and Medicaid Services) that can be used to review a service for medical necessity/ medical appropriateness also contributes to decisions about what services may require prior authorization (we need criteria to review against). For the IHN-CCO line of business, information contained within the Oregon Prioritized List, including Guideline Notes published by the Oregon Health Authority, also contributes to decisions about what services should require prior authorization. Prior authorization lists are managed by the Care Coordination Department. They are updated annually with input from multiple departments within SHP, including Care Coordination and require external regulatory review.

Minimum health record requirements for hospitals and behavioral health hospitals Each member’s record must include information needed to perform prior authorization. This information must include, at least, the following:

z Identification of the member. z Date of operating room reservation, if applicable. z The name of the member’s health care z Justification of emergency admission, provider. if applicable. z Date of admission and dates of application z Reasons and plan for continued stay, if the for and authorization of Medicaid benefits if attending provider believes continued stay application is made after admission. is necessary. z The plan of care. z Other supporting material that the z Initial and subsequent continued stay committee believes appropriate to be review dates. included in the record.

For more specific information, please reference the SHP medical record standards.

Prior authorization list The prior authorization list includes services and procedures requiring review prior to the member receiving care. The list is plan-specific and published on the Samaritan Health Plans website and in the member benefit materials. The prior authorization list is designed to eliminate barriers for members with chronic conditions and/or special health care needs. Care Coordination policies, procedures and criteria outline utilization requirements for most procedures, diagnostic treatments, provider specialties and code or item-specific detailed requirements prior to authorizing. Authorization request determinations are made using evidence-based, established local, state or nationally accepted criteria adhering to regulatory and plan-specific requirements.

IHN-CCO Utilization Management and Service Authorization Handbook 3 Authorization specialist review The authorization specialist’s role is to verify eligibility, benefits and provider status and data entry and to process determination letters, as well as request and track medical and health records. With training and supervision, the authorization specialist may process certain authorizations following written guidelines for the auto-authorization process. The authorization specialist will refer all requests that do not meet criteria for auto-authorization to clinical review and organizational determination.

Clinical review All authorization requests that do not meet the auto-authorization list written guideline or that require clinical criteria review will be reviewed by a licensed registered nurse (RN) (clinical care manager), licensed practical nurse (LPN) (clinical care guide), licensed clinical social worker (LCSW)/licensed professional counselor (LPC) (behavioral health care manager), certified durable medical equipment (DME) coordinator or other appropriately licensed clinical specialist to complete the review. Authorization requests requiring clinical review will have the appropriate criteria applied as part of the review process. Criteria source examples may include but are not limited to: Oregon Health Authority Prioritized List of Health Services, Guideline Notes, Oregon Administrative Rules (OAR), Oregon Revised Statutes (ORS), National and Local Medicare Coverage Determinations, Medical Coverage Policies and MCG guidelines.

Service types

z Alcohol and drug residential: Outpatient chemical dependency (CD) services or substance use disorder (SUD) services for our members include inpatient hospitalization for medical detoxification, intensive outpatient and outpatient substance use treatment. We currently contract with multiple substance use providers across several counties to meet the needs of our members seeking substance use treatment. Coordinating resources is a collaborative effort between the Care Coordination Department, providers, hospitals, community programs and resources. z Ambulance/medical transport: Medically necessary transportation of a member to hospital, facility or medical service. Methods of transportation include land, water or air. z Dental services: Diagnostic treatment and all aspects of oral health delivery for members in a comprehensive, continuously accessible, coordinated and person-centered process. Services provided by a qualified dental professional in an office or inpatient setting. z Diagnostic studies: Examination to identify diagnosis. Services include all testing and imaging to determine a condition, disease or illness provided in an outpatient facility or inpatient setting. This includes CT scans, PET scans and other diagnostic tests excluding MRI/MRA. z Durable medical equipment (DME): Durable medical equipment, prosthetics, orthotic devices or supplies are authorized by certified DME coordinators and appropriately trained RNs within the department. Authorization requirements may be plan-specific. z Emergency services: Services furnished in an emergency department and ancillary services routinely available to an emergency department that may be needed to stabilize a patient do not require referrals or prior authorization. The definition of an emergency is based on a prudent layperson’s judgment. An emergent condition requires stabilization and may require ongoing care coordination and case management.

IHN-CCO Utilization Management and Service Authorization Handbook 4 z Hospital: Inpatient/facility services where the clinical care manager, clinical care guide and/or behavioral health care manager team members telephonically coordinate care, review documentation for quality and care and facilitate transitions for members at contracted and out-of-network facilities. z Inpatient mental health: Mental health treatment provided at the Samaritan Health Services (SHS) Mental Health Unit and through our network of contracted mental health facility providers. Members are triaged from the emergency room, home, community or from another facility for care. This setting offers the highest level of physical security and most intensive level of intervention. Concurrent review for inpatient mental health is provided by the Care Coordination Department using MCG guidelines for reviewing medical necessity and length of stay. z Mental health: Includes outpatient services in the treatment of conditions of psychological and emotional well-being. Excludes hospital and residential services. z Magnetic resonance imaging (MRI): Diagnostic services that use magnetic fields and radio waves to produce a detailed image of the body’s soft tissue and bones. This service type also includes magnetic resonance angiogram (MRA) to provide pictures of blood vessels inside the body. z Non-emergency medical transport (NEMT): Transportation to and from medical appointments for members with no other means of transportation. z Occupational, physical and speech therapy: Services provided in an inpatient facility or outpatient setting by a qualified provider. Therapies for members recuperating from medical procedures, surgical conditions or mental illness that encourage rehabilitation through the performance of activities required for daily life. z Outpatient services: Certain outpatient services, including diagnostic, procedural, limited specialist visits, speech therapy, occupational and physical therapy, transplants and other procedures or services requiring prior authorization, are published in the member benefit guide. z Out-of-network services: Nonparticipating or non-contracted providers will have their requests processed in the same manner as contracted providers. Service and treatment will be approved on a case-by-case basis and depend on the plan and/or individual case considerations. Behavioral health services may be provided by non-contracted providers when: z Service to a contracted provider is not available in an appropriate time frame z Member resides outside the CCO region (i.e. in a behavior rehabilitation services or adult residential program), or; z Specialty provider required for services is not available through the network. z Pain management: Medical approach that draws on disciplines in science and alternative healing to study the prevention, diagnosis and treatment of pain. Pain management services provided in an outpatient setting by a qualified provider. z Primary care provider: Services provided in an outpatient setting by member primary care provider who is a credentialed and qualified billing provider. z Psychiatric day treatment: Comprehensive, interdisciplinary, non-residential, community-based program consisting of psychiatric treatment, family treatment and therapeutic activities integrated with an accredited education program. z Residential rehabilitation: Treatment received at a residential substance abuse facility or psychiatric residential treatment center. This 24/7 setting is an alternative to more intensive inpatient treatment and authorized when the benefit allows to treat psychiatric illness and substance use disorder as clinically appropriate.

IHN-CCO Utilization Management and Service Authorization Handbook 5 z Skilled nursing facility (SNF): SNF services provided in a medical rehab facility. This covers a continuum of medical and social services designed to support the needs of members recovering from conditions that affect their ability to perform everyday activities. z Specialty care: Surgical or medical specialty care provided in an outpatient or inpatient setting by a qualified provider.

Review types

z Pre-service review: Review of services/treatments prior to the service date is considered pre-service or prior authorization. Prior authorization requests account for the highest volume of requests reviewed in the department. These include planned inpatient hospitalizations or procedures, outpatient services and home health items, services and/or equipment. z Concurrent review: A review to determine extending a previously approved, ongoing course of treatment or services. Concurrent reviews are typically associated with inpatient care, skilled nursing facility, residential behavioral health care, intensive outpatient behavioral health care and ongoing ambulatory care. z Post-service review: The process of reviewing services or treatment after the date of service occurs is considered post-service review. Post-service review of services that require prior authorization is limited by exception reasons. If an exception is granted the same criteria and plan benefits and guidelines are applied to the request or case as would be applied for pre-service requests.

Utilization management criteria The plan’s evidence of coverage (EOC) or plan document, use federal and state guidelines to determine benefits. Nationally recognized criteria, federal (CMS), state, internal practice guidelines and company- developed clinical standards are used to determine clinical and medical appropriateness of services. The criteria are selected, developed, approved and overseen by the IHN-CCO leadership team. The organization gives practitioners with clinical expertise in the area being reviewed, the opportunity to advise or comment on the development or adoption of criteria. The IHN-CCO leadership team works closely with Care Coordination leadership to ensure clinical consistency and appropriateness of all criteria utilized by the Care Coordination Department. Complete criteria sets are maintained electronically and are available for reference to authorized entities, providers and members upon request.

Evidence-based criteria IHN-CCO performs utilization management using nationally recognized evidence-based guidelines from MCG Health. Care guidelines from MCG provide evidence-based medicine’s best practices and care plan tools across the continuum of treatment, providing clinical decision support and documentation which enables efficient transitions between care settings. Eight of the largest United States health plans and nearly 1,900 hospitals use MCG Health’s evidence-based guidelines and software. MCG Health’s informed care strategies affect over 208 million covered lives.

IHN-CCO Utilization Management and Service Authorization Handbook 6 Criteria examples z American Society of Addiction Medicine: asam.org/asam-criteria z MCG CareWebQI 11.0.4 MCG Health: mcg.com/care-guidelines/overview z For Samaritan’s Medicare Advantage Health Plans, we use applicable content from:

z Medicare National Coverage Determinations, Local Coverage Determinations and the Medicare Benefit Policy Manual.

z CMS Medicare National Coverage Determinations: cms.gov/Regulations-and-Guidance/ Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS014961

z CMS Medicare Local Coverage Determinations: cms.gov/medicare/coverage/determinationprocess/LCDs

z Medicare Benefit Policy Manual: cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/ CMS012673 z Our InterCommunity Health Network CCO plan follows coverage guidelines and funding limitations that govern the Oregon Health Plan (Oregon Medicaid) established by the Oregon legislature and Oregon Health Authority in the Prioritized List of Health Services and Oregon Administrative Rules:

z Oregon Medicaid Prioritized List (which includes above the line and below the line information as well as guideline notes developed by the state Health Evidence Review Commission): oregon.gov/OHA/HPA/CSI-HERC/Pages/Prioritized-List

z Oregon Administrative Rules: secure.sos.state.or.us/oard/ruleSearch.action On the rare occasion that no appropriate guideline exists from the sources above, IHN-CCO uses a small number of internally developed Samaritan Health Plan medical coverage policies, found at providers.samhealthplans.org/medical-coverage-policies. It should be noted that the conclusion a service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by IHN-CCO) for a member. The member’s benefit plan determines coverage. Each benefit plan defines which services are covered, which are excluded and which are subject to dollar caps or other limits. Clinical reviewers consider the individual characteristics of the member, i.e., age, comorbidity, complications, progress of treatment, psychosocial situation, care supports and home environment when applying criteria.

Request types Requests for services or items and decision notification time frames are consistent with applicable state and federal laws and regulations and accreditation standards. Detailed explanations and timelines are outlined in decision support tools and department policies and procedures.

z Expedited: When a service request is expedited, a provider is documenting that the member’s health condition cannot wait the standard authorization time frame to receive a response (see table 1).

IHN-CCO Utilization Management and Service Authorization Handbook 7 z Standard: Each line of business has a regulatory time frame to process a standard request. When a request is incomplete or requires a more extensive review, additional time may be necessary to process the request. It is the responsibility of the plan to reach out a minimum of three times to request additional documentation and then refer to the plan medical director for follow-up (see timelines below). z Retroactive: A post-service or retroactive request may be reviewed up to one year past the date of service. Retroactive requests are processed within 14 days of receipt for all lines of business except Commercial Plans which are processed within two business days.

Notification process Members may receive written notification of the authorization determination by mail. Each plan requirement is documented in Care Coordination policies and procedures. In addition, phone calls, faxes, letters and e-mails are documented and maintained per regulatory requirements.

Prior authorization request processing timeline requirements:

Line of business Expedited time frame Standard time frame Samaritan Advantage Health Plans 72 hours 14 days Samaritan Advantage Health Plans 24 hours 72 hours Part B drugs IHN-CCO 72 hours 14 days IHN-CCO provider administered drugs 72 hours 72 hours Samaritan Choice Plans 72 hours 14 days Samaritan Employer Group Plans 72 hours Two business days Table 1

Denials / appeals A denial is a decision to limit or deny authorization of a requested service or item that is published as requiring authorization from Care Coordination. This is defined by Centers for Medicaid and Medicare as an adverse organizational determination. Whenever issuance of a denial is warranted, the member will receive notice in writing which is copied to the provider. The written notification of a denial of coverage is based upon medical appropriateness or benefit limitation and will include, but is not limited to: z Reason for the adverse determination in terms specific to the member’s condition. z Description of the member’s treatment interventions requested. z Specific criteria deemed to be appropriate to apply to the specific request indicating (when appropriate and applicable) which portion of the criteria was not found to be met. z Description of the member’s appeal rights and how to initiate an appeal.

IHN-CCO Utilization Management and Service Authorization Handbook 8 The chief medical officer or medical director is available to discuss the decision with the provider regarding an adverse determination. This is called a “peer-to-peer” consultation and may result in the decision being overturned. The intent is to provide an opportunity to discuss the details of a specific case for better understanding as to why the request may not have met the required criteria. Any request that is denied can be appealed by a member or their authorized representative. All lines of business have individual appeal processes including internal and external review. An impartial provider, who was not involved in the initial denial, makes the redetermination of medical necessity.

Confidentiality Care Coordination staff follow all Samaritan Health System (SHS) and Samaritan Health Plans (SHP) HIPAA policies as they relate to procedures, access, safeguards and security of protected health information (PHI). IHN-CCO ensures that, through the process of coordinating care, each member’s privacy is protected in accordance with the privacy requirements in 45 CFR parts 160 and 164, subparts A and E, to the extent they are applicable. The policies are reviewed with all staff upon hire and annually.

Financial incentives IHN-CCO does not use financial or other incentives to encourage over or underutilization. Decision-making is based only on member eligibility and appropriateness of care and service. IHN-CCO physicians and staff make decisions about which care and services are provided based on the member’s clinical needs, the appropriateness of care and service and the member’s coverage. IHN-CCO does not make decisions regarding hiring, promoting or terminating its physicians or other individuals based upon the likelihood or perceived likelihood that the individual will support or tend to support the denial of benefits. IHN-CCO does not specifically reward, hire, promote or terminate practitioners or other individuals for issuing denials of coverage or care. No financial incentives exist that encourage decisions that specifically result in denials or create barriers to care or services. To maintain and improve the health of our members, all physicians and health care professionals should be especially diligent in identifying any potential underutilization of care or services.

IHN-CCO Utilization Management and Service Authorization Handbook 9 Quality and performance improvement

Care Coordination takes a systematic and data-driven approach to evaluating, maintaining and improving the quality and safety of services delivered to our members. The department is focused on training and continuous improvement and uses the Agency for Healthcare Research and Quality (AHRQ) PDSA model of improvement.

Inter-Rater Reliability The purpose of Inter-Rater Reliability (IRR) testing is to monitor and evaluate consistency of internal utilization review decision-making according to established standards. These standards address specifications for conducting effective and efficient utilization management services. The results are evaluated for opportunities to improve consistency in decision-making. IRR testing is completed on an annual basis by all clinical and medical reviewers making determinations, including medical directors, nurses, providers and behavioral health professionals. Case study examples are compiled of typical authorizations that are encountered within the department that require clinical and/or medical review. The testing for these cases utilizes the criteria utilized for the specific plan represented. This includes MCG evidence-based software, CMS standards, Medicare Benefit Policy Manual, Medical Coverage Guidelines (National Coverage Determinations (NCD) and Local Coverage Determinations (LCD)), SHP approved clinical policies, American Society of Addiction Medicine (ASAM) and Oregon Administrative Rules including Guideline Notes and the Prioritized List. Documented determinations of the case studies are compared for percentage of agreement of the reviewers. An overall percentage of 85% or higher is the acceptable standard. The annual IRR review will be completed annually each calendar year. The most current annual IRR percentage rate is 96%.

IHN-CCO prior authorization list

Current prior authorization lists may be found on the Samaritan Health Plans website: providers.samhealthplans.org/Authorizations

IHN-CCO Utilization Management and Service Authorization Handbook 10 IHN-CCO Care Coordination policies CSD-CC-UM-02 IHN-CCO Authorization Request Policy - SHP

Application / scope Care Coordination utilization management staff, Network Strategy and Contracting

Definitions 1. Adverse Benefit Determination (Denial):Defined as any of the following: a. The denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical appropriateness, OR b. The reduction, suspension, or termination of a previously authorized service, OR c. The denial, in whole or in part, of payment for a service, OR d. The failure to provide authorization in a timely manner, as defined by the Oregon Health Authority (OHA) and Centers for Medicare and Medicaid Services (CMS). 2. Appeal: The right of the member or member’s authorized health care representative to request reconsideration or redetermination of an authorization that resulted in denial. 3. Authorization Request: The request for approval of a health care product or service such as a specific medical treatment, surgical procedure or diagnostic test. 4. Auto-Approval: Approval of a health care product or service based on established criteria determined appropriate by the Medical Director. 5. Duplicate Request: Defined as meeting any of the following descriptions: a. A request that is submitted by the same provider, for the same member, with the same International Classification of Diseases (ICD) diagnosis coding and Current Procedural Terminology (CPT)/Healthcare Common Procedure Coding System (HCPCS) coding within the appropriate appeal timeframe for the line of business OR b. A request that includes additional clinical documentation but is resubmitted by the same provider, for the same member, with the same ICD coding and CPT/HCPCS coding within the appropriate appeal timeframe for the line of business on a previously denied request, OR c. Any authorization request that includes wording within the request such as “reconsideration” or “review” or any other additional wording that would indicate the submitting provider office is requesting an additional review of an authorization request that has been previously reviewed with a recorded outcome determination. 6. Durable Medical Equipment (DME): Items and supplies, both rented or owned, that provide therapeutic benefits to a member in need because of certain medical conditions and/or illness. DME must be able to withstand repeat use in the member’s home.

IHN-CCO Utilization Management and Service Authorization Handbook 11 7. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction or any bodily organ or part. An emergency medical condition is determined based on the presenting symptoms (not the final diagnosis) as perceived by a prudent layperson (rather than a health care professional) and includes cases in which the absence of immediate medical attention would not in fact have had the adverse results described in the previous sentence. 8. Emergency Services: Health services from a qualified provider necessary to evaluate or stabilize an emergency medical condition, including inpatient and outpatient treatment that may be necessary to assure within reasonable medical probability that the member’s condition is not likely to materially deteriorate from or during a member’s discharge from a facility or transfer to another facility. 9. Expedited (Urgent) Request: A request for a health care product or service where application of the time frame for making routine or non-life-threatening care determinations: a. Could seriously jeopardize the life, health or safety of the member or others, due to the member’s psychological state; or b. In the opinion of a practitioner with the knowledge of the member’s medical or behavioral condition, would subject the member to adverse health consequences without the care or treatment that is subject of the request. 10. Invalid Request: An authorization request that is missing required data elements. 11. Medically Appropriate: Health services, items, or medical supplies that are: a. Recommended by a licensed health provider practicing within the scope of their license; b. Safe, effective, and appropriate for the patient based on standards of good health practice and generally recognized by the relevant scientific or professional community based on the best available evidence; c. Not solely for the convenience or preference of an IHN-CCO member, or a provider of the service item or medical supply; and d. The most cost effective of the alternative levels or types of health services, items, or medical supplies that are covered services that can be safely and effectively provided to an IHN-CCO member in IHN-CCO judgement; e. All covered services must be medical appropriate for the member, but not all medically appropriate services are covered services. 12. Medically Necessary: Health services and items that are required by a member to address one or more of the following: a. The prevention, diagnosis, or treatment of a member’s disease, condition, or disorder that results in health impairments or a disability; b. The ability for a member to achieve age-appropriate growth and development; c. The ability for a member to attain, maintain, or regain independence in self-care, ability to perform activities of daily living or improve health status; or

IHN-CCO Utilization Management and Service Authorization Handbook 12 d. the opportunity for a member receiving Long Term Services & Supports (LTSS) to have access to the benefits of non-institutionalized community living, to achieve person centered care goals, and to live and work in the setting of their choice; e. A medically necessary service must also be medically appropriate. All covered services must be medically necessary but not all medically necessary services are covered services. 13. Post Stabilization Services: Covered services, related to an emergency medical condition, that are provided after a member is stabilized in order to maintain the stabilized condition, or, under the circumstances to improve or resolve the member’s condition. 14. Prior Authorization: A pre-service request for evidence-based clinically appropriate health plan review and determination of health care services under the applicable benefit plan. Each line of business has a list of services that require authorization prior to the service being completed which is updated annually and posted to the health plan website. Contracted providers agree to be familiar with services that require prior authorization. Services that require prior authorization may include, but are not limited to, surgical services, diagnostic testing, items of DME, etc. Prior authorization is not required for urgent care or emergency services as defined herein. 15. Provider Administered Drug: Medications that are infused or administered by a healthcare practitioner in an outpatient setting which may include a physician’s office, infusion center or outpatient clinic. 16. Received Date: The date the request is received by the health plan. This date is counted as Day 0. 17. Retroactive “Retro” (Post- service) Request: A request for authorization of a health care product or service that has already been received. 18. Standard (Non-urgent Pre-service) Request: A request in advance for authorization of a health care product or service for which application of the time periods for making a decision does not jeopardize the life or health of the member or the member’s ability to regain maximum function and would not subject the member to severe pain. 19. Urgent Care Services: Health services that are clinically appropriate and immediately required to prevent serious deterioration of a member’s health that are a result of unforeseen illness or injury. 20. Valid New Request: An authorization request where all of the required data elements are present.

Policy Care Coordination utilization management staff ensure accurate and timely processing of prior authorization requests related to DME, medical procedures and services including mental health and substance use disorder services. Care Coordination utilization management staff ensure that appropriate clinical information is obtained, documented, and reviewed for all utilization management decisions. This process may include consulting with the requesting provider when appropriate.

Procedure 1. Authorization Requests a. Samaritan Health Plans (SHP) classifies authorization requests as either expedited or standard. Authorization requests may also be reviewed for indications that the requested service has been scheduled.

IHN-CCO Utilization Management and Service Authorization Handbook 13 b. Requests are accepted in writing via fax, phone, electronic submission through the provider portal or by secure email. Contracted providers must submit requests via electronic submission using the provider portal, Provider Connect. Registration for Provider Connect is required through OneHealthPort. c. All authorization requests are time/date noted upon receipt. i. Authorization requests received on weekends, on official SHP holidays, or on emergency closure days are to be processed using the received date/time indicated on the request regardless of if the request was technically received during a date/time which SHP was officially closed. ii. Appropriate maintenance of department date/timestamp equipment is the responsibility of department manager or designee. d. All authorization requests are reviewed for member eligibility at the time of service. e. The IHN Prior Authorization list is designed to eliminate barriers for members with chronic conditions and/or special health care needs. Long Term Services and Supports (LTSS) determinations are made by Oregon Cascades West Council of Governments Senior and Disability Services within our region. f. All authorization requests are determined to be valid or invalid within two business days following receipt. g. All authorization requests are reviewed for fraud, waste and abuse in accordance with SHP’s Fraud, Waste and Abuse Program. h. All authorization requests are processed according to the contractual state and/or federal regulations within the appropriate timeframes as specified in the table below.

Standard authorization Expedited authorization Can we decline Physician signature time frames time frames expedited status? required for expedition? 14 calendar days* 72 hours* By regulation, yes; No Provider Administered Provider Administered however, per SHP practice, Drugs are processed Drugs are processed we do not decline within 72 hours. within 72 hours. requested expedited status when indicated as such by the provider. Timeline extension May extend once for up to 14 calendar days with proper communication to member and to requesting provider. Provider Administered Drugs cannot be extended. * Authorization requests related to drugs, alcohol, drug services or care while in a SNF are processed within two business days following receipt. Prior authorization requirements are designed to eliminate barriers to care. Non-emergent behavioral health hospitalization or residential care prior authorization determinations are made within three (3) days of receipt of request.

IHN-CCO Utilization Management and Service Authorization Handbook 14 i. When there is failure to complete a final outcome determination with appropriate communications to the member and provider within the required timeframes, a Compliance Incident Report will be submitted, and the process failure will be immediately addressed with appropriate staff. i. At no time will the full authorization process be applied to a request identified as a duplicate or invalid request. j. Authorization requests received for IHN-CCO members who also have other coverage will be voided. Authorizations are not required by IHN-CCO when IHN-CCO is the member’s secondary plan. i. When IHN-CCO members are also covered as Special Needs Plan (SNP) members on SamaritanAdvantage Health Plan (SAHP): a. Authorization requests will be reviewed based on SAHP benefits and authorization policies. b. IHN-CCO benefits will be applied if the request is for an item or service for which there is not a benefit available within SAHP. k. Authorization requests for Indian Members will be not be considered out-of-network when services are provided by a non-participating Indian Health Care Provider pursuant to 42 CFR §438.14(b)(4) and (6). l. Post stabilization services may be provided by both contracted and non-contracted providers as described in CLM-80 IHN-CCO Coverage for Non-Participating Provider Urgent Care, Emergency and Ambulance Services and IHN.17.004.AM Emergency and Post Stabilization Services. Prior Authorization for post stabilization services may be required after discharge. It is understood that discharge or transfer determinations are the responsibility of the attending emergency physician or provider treating the member. 2. Retroactive authorization requests are accepted only if the request meets the exceptions and/ or extenuating circumstances listed in CSD-CC-UM-51 Retroactive Authorization Requests Policy. Qualifying requests are processed as a standard authorization request. 3. Expedited Authorization Requests a. Care Coordination utilization management staff determine within 24 hours of receiving an expedited request if the expedited requirements have been met. b. All final outcome determinations to the member or the member’s authorized representative will include the appropriate explanation of the member’s rights to file an expedited appeal with the health plan. c. Retroactive authorization requests will not be considered as expedited. d. Valid requests for Provider Administered Drugs will be processed expeditiously as defined in Oregon Administrative Rules (OAR) 410-141-3855 and 410-141-3835 4. Invalid Requests a. Care Coordination utilization management staff are required to make a minimum of 3 documented attempts to obtain the missing data elements.

IHN-CCO Utilization Management and Service Authorization Handbook 15 b. An extension letter will be sent if the information is not received in the appropriate time frame based on referral type (See table in 1H above). c. If the information is not received after the above-mentioned attempts, the authorization request is then considered to be invalid. The requesting provider will be given final notification that the request is unable to be processed. 5. Levels of Utilization Review a. Internal Review — All valid authorization requests will receive an internal review to assess the documentation provided and document any additional findings for clinical review, or auto- approval. Requests for additional documentation are made as early as possible in the internal review process. b. Clinical Review — All authorization requests that require clinical review must be assessed by a clinical Care Coordination utilization management staff member with credentials and training appropriate to the request (i.e. Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified Durable Medical Equipment (CDME) personnel, Assistive Technology Personnel (ATP), Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC). All Clinical Reviewers have knowledge of Medicare coverage criteria, Oregon Administrative Rules and Guideline Notes, and clinical practice guidelines. c. Medical Review — All authorization requests that do not meet established criteria will be forwarded to Medical Review for a determination by a Medical Doctor (MD), Doctor of Osteopathic Medicine (DO) who has knowledge of Medicare coverage criteria, Oregon Administrative Rules and Guideline Notes, and clinical practice guidelines. Behavioral Health requests may also be reviewed by a doctoral level clinician (PhD, PsyD). 6. Outcome Determination a. Samaritan Health Plans does not use financial incentives to encourage over or underutilization. Decision making is based only on member eligibility and appropriateness of care and service. b. Requesting providers are consulted for review of services when appropriate. c. Completion of all medical review requirements will result in a documented outcome determination consisting of one of the following: i. Authorized Services a. Approved ii. Adverse Benefit Determination a. Denied b. Partially denied/partially approved c. For termination, suspension or reduction of previously approved covered services, written notification will be sent to the member at least 10 days before the planned action unless otherwise specifically authorized in CCO contract. Notification will be sent to the member at least five days before the planned action when probable member fraud has been verified. a. Exception to this rule: i. IHN-CCO will mail a notice no later than the date of action if

IHN-CCO Utilization Management and Service Authorization Handbook 16 1. The CCO has factual information confirming the death of the member; 2. The CCO receives a clear written statement signed by the member that; a. The member no longer wishes services; or b. Gives information that requires termination or reduction of services and indicates the member understands that this must be the result of supplying that information. 3. The member has been admitted to an institution where the member is ineligible under the plan for further services; 4. The member’s whereabouts are unknown and the post office returns mail directed to the member indicating no forwarding address; 5. The CCO establishes the fact that the recipient has been accepted for Medicaid services by another local jurisdiction, State, territory or commonwealth; 6. A change in the level of medical care is prescribed by the member’s physician; 7. The notice involves an adverse benefit determination made with regard to preadmission screening requirements; or 8. The date of action will occur in less than 10 days. d. Decisions to deny, reduce or authorize a service in an amount, duration, or scope less than what was requested are made by health care professionals with appropriate clinical expertise. d. All documents utilized and or generated as a result of an outcome determination will be retained within a secure electronic record system and/or in accordance with SHP’s Data Storage and Destruction Policy. 7. Notifications a. Appropriate member/authorized representative and provider notification will be prepared and distributed following all applicable policies and regulations. Appropriate notification may consist of verbal, telephonic, fax, written and/or electronic communication. b. Member and provider notifications will be written in language that is easy to understand. c. Adverse Benefit Determinations i. The reason for denial will be stated in terms specific to the member’s condition. ii. Out-of-network denials will address whether or not the requested service can be provided within the network. iii. Criteria referenced will be identified by name and specific to an organization or source. Criteria will be made available upon request. iv. A description of appeal rights along with an explanation of the appeal process and expedited appeal process are included with every denial notification. v. Providers will be provided with an opportunity to discuss the denial with a physician or other appropriate reviewer.

IHN-CCO Utilization Management and Service Authorization Handbook 17 8. Protecting Health Information a. Care Coordination utilization management staff follow all Samaritan Health System (SHS) and Samaritan Health Plans (SHP) HIPAA policies as they relate to procedures, access, safeguards and security of protected health information (PHI). IHN-CCO ensures through the process of coordinating care each parts 160 and 164 subparts A and E, to the extent they are applicable.

References 1. CFR 42 Part 422-570, 422-574, 438-210, 422-626(E)(1), 438.408, 438.14(b)(4) and (6) 2. 29 CFR 2560.503-1, 29 CFR 2520.104b-1(c)(1)(i)(iii), and (iv) 3. Social Security Act section 1919(e)(7) 4. OAR 410-120-0000, 410-141-3820, 410-141-3835, 410-141-3855, 410-141-3920 5. Oregon Health Plan contract #143116-10, Exhibit I 6. Medicare Managed Care Manual, Chapter 4, Section 20.2 7. NCQA Standards and Guidelines for the Accreditation of Health Plans

Reference #: 1499 Paper copies of this document may not be current and should not be relied on for official purposes. The current version is in PolicyTech.

IHN-CCO Utilization Management and Service Authorization Handbook 18 CSD-CC-UM-21-IHN-CCO Criteria for Utilization Management Decision Making Policy - SHP

Application / scope SHP Chief Medical Officer (CMO), Medical Director(s), contracted physician reviewers, Medical Management staff, Appeals staff

Definitions 1. Addictions and Mental Health (AMH): A division within the Oregon Health Authority (OHA) whose mission is to assist Oregonians to achieve physical, mental and social well being by providing access to health, mental health and addiction services and supports to meet the needs of adults and children to live, be educated, work and participate in their communities. 2. American Society of Addition Medicine (ASAM): Patient Placement Criteria for the treatment of Substance-related disorders ASAM PPC-2R. 3. Clinical Practice Guidelines: Systematically developed statements, or recommendations to assist provider and member decisions about appropriate health care for specific circumstances. 4. Clinical Reviewer: Used to represent Clinical Care Guides, Clinical Care Managers, Behavioral Health Care Managers and/or DME Coordinators who perform clinical review of authorization requests. 5. MCG: MCG Corporation’s evidence-based criteria available to SHP Clinical Reviewers via web based software with issued user name and password. 6. Medical Appropriateness/Medically Necessary: Defined as accepted health care services and supplies provided by health care entities appropriate to the evaluation and treatment of disease, condition, illness or injury and consistent with the applicable standard of care. 7. Medicare Coverage Guidelines: The National Coverage Determinations (NCD’s) and Local Coverage Determinations (LCD’s) available to Clinical Reviewers via cms.gov/Medicare/Coverage/CoverageGenInfo. 8. SHP Medical Coverage Policies: A series of policies developed by SHP based on local, regional and national practice standards, literature researched, and consensus of appropriate SHP team members. Recommended policies must be endorsed by the Quality Improvement Committee (QIC) to be considered an SHP developed and approved policy.

Policy The SHP Chief Medical Officer, Medical Director(s), contracted physician reviewers, the Medical Management utilization management staff and Appeals staff must use the specific criteria contained within to ensure consistency and applicability in utilization management decisions. When applying the specific criteria to authorization requests, the additional aspects listed in this policy are also incorporated into the utilization management decision making process.

IHN-CCO Utilization Management and Service Authorization Handbook 19 Procedure 1. SHP applies all plan benefit rules, including benefit limits, prior to a medical necessity review. This includes, but is not limited to application of the Oregon Health Plan Prioritized List, List of Non- covered Services and the IHN-CCO Member Handbook. 2. When applying criteria, SHP evaluates clinical practice guidelines, standards and policies for dental care, medical and behavioral health practice to ensure alignment with evidence-based practice, community standards and relevant law. 3. Criteria Order a. SHP uses Primary Criteria if it exists for the health care product, service or item requested. b. If Primary Criteria does not exist, or is not applicable, this is documented within the case review file, and SHP uses Secondary Criteria. c. Similarly, if Primary and Secondary Criteria do not exist or is not applicable, this is documented within the case review file and SHP uses Tertiary Criteria. 4. Timeframes for clinical guidance a. Oregon Administrative Rules (OARs) and/or Guideline Notes should be utilized when applicable. b. Guideline Notes should be utilized from the current effective prioritized list only. (Routinely updated April and October of each year with rare incidental updates to address urgent update needs). Retroactive guideline notes should only be used for corresponding retroactively submitted authorization requests. Otherwise the most recent guideline note should always be applied. c. MCG Guidelines — The most current MCG criteria available in relation to the date of service should always be utilized for all authorization requests. d. ASAM — The most current ASAM in relation to the date of service should always be utilized for all behavioral health authorization requests. e. Medicare Coverage determinations may be made using the following if applicable: i. NCD — Policies created by Centers for Medicare & Medicaid Services (CMS) that define extent to which Medicare will cover specific services, procedures or technologies on national basis. ii. LCD — Policy developed by Medicare Contractors to apply to a service, item or drug that does not have an NCD; may also supplement an NCD to further define coverage but cannot restrict or conflict with an NCD. iii. Medicare Managed Care Manual iv. Medicare Benefit Policy Manual f. SHP Medical Coverage Policies — The most current SHP Medical Coverage Policy in relation to the date of service should always be utilized for all authorization requests. 5. Non-contracted provider services will be evaluated for in-network availability of the same service. All out-of-network services will be referred to the Medical Director(s) for review. 6. SHP uses the criteria listed in the table below when reviewing authorization requests.

IHN-CCO Utilization Management and Service Authorization Handbook 20 IHN-CCO — Medical Necessity Criteria

Services Primary criteria Secondary criteria Tertiary criteria Inpatient OARs to include Guideline MCG criteria a. Medicare Coverage Guidelines hospital stays Notes and Prioritized List b. SHP Medical Coverage Policy Surgical services OARs to include Guideline MCG criteria a. Medicare Coverage Notes and Prioritized List Guidelines (NCD/LCD only) b. SHP Medical Coverage Policy c. Clinical Practice Guidelines Imaging services OARs to include Guideline MCG criteria a. Medicare Coverage Notes and Prioritized List Guidelines (NCD/LCD only) b. SHP Medical Coverage Policy c. Clinical Practice Guidelines Skilled nursing OARs to include Guideline Medicare Benefit SHP Medical Coverage Policy facility/inpatient Notes and Prioritized List Policy Manual Ch. 8 rehab services Durable medical OARs to include Guideline MCG criteria a. Medicare Coverage equipment and Notes and Prioritized List Guidelines (NCD/LCD only) supplies b. SHP Medical Coverage Policy Mental health OARs to include Guideline a. ASAM a. Medicare Coverage and chemical Notes and Prioritized List b. MCG criteria Guidelines (NCD/LCD only) dependency services b. SHP approved Clinical Policy PT, OT and ST a. OARs to include Guideline MCG a. Medicare Coverage services Notes and Prioritized List Guidelines (NCD/LCD only) b. Medical Coverage b. SHP Medical Coverage Policy Guidelines (only if indicated c. Clinical Practice Guidelines by specific OAR/rule) Other a. OARs to include Guideline MCG a. Medicare Coverage outpatient services Notes and Prioritized List Guidelines (NCD/LCD only) b. Medical Coverage Guidelines b. SHP Medical Coverage Policy (only if indicated by specific c. Clinical Practice Guidelines OAR/rule) Home health a. OARs to include Guideline MCG a. Medicare Coverage Notes and Prioritized List Guidelines (NCD/LCD only) b. Medical Coverage Guidelines b. SHP Medical Coverage Policy (only if indicated by specific OAR/rule) Non-contracted OARs to include Guideline SHP Medical Coverage Policy provider aspect of Notes and Prioritized List authorization request

IHN-CCO Utilization Management and Service Authorization Handbook 21 7. As nationally developed procedures for applying criteria are often designed for “uncomplicated” patients and for a comprehensive delivery system, they may not be appropriate for patients with complications or for a delivery system with insufficient alternatives to inpatient care. SHP therefore considers the following when applying criteria to a given individual: a. Age b. Comorbidities c. Complications d. Progress of treatment e. Psychosocial situation f. Home environment, when applicable g. Availability of skilled nursing facilities, subacute facilities or home care in the service area (if needed to support the patient after hospital discharge) h. Coverage of benefits for skilled nursing facilities, subacute care facilities or home care where needed i. Local hospitals ability to provide all recommended services within the estimated length of stay These characteristics are reviewed and Medical Management staff are instructed to alert the reviewing physician when any of the above factors indicate that criteria guidelines may not be appropriate. These cases are reviewed individually by the Physician Reviewer for appropriate determinations.

References 1. NCQA Standards & Guidelines for the Accreditation of Health Plans UM-2 2. MM-02 Policy: IHN-CCO Authorization Requests

Reference #: 2052 Paper copies of this document may not be current and should not be relied on for office purposes. The current version is in PolicyTech.

IHN-CCO Utilization Management and Service Authorization Handbook 22 Online prior authorization instructions 1. Navigate to One Health Port. Select the Single Sign-On login link, then select Samaritan Health Plans from the Participating Sites by clicking on the corresponding logo. 2. Log in with your One Health Port assigned user name and password.

3. Agree to Terms of Use.

4. Select the practitioner or group that is requesting the prior authorization for care.

IHN-CCO Utilization Management and Service Authorization Handbook 23 5. Select the tab for Authorizations, then select New Authorization.

6. Read the authorization requirements on the Welcome screen, then click Next.

7. The next screen is for the requesting staff information (referral specialist), followed by the requesting provider information. The requesting provider typically must be an individual practitioner, not a group or facility. Depending on the specific request, proceed according to one of the options below: a. If the practitioner referring/requesting the care is already showing under Requesting Provider, go to step 12. b. If the provider you selected in step 4 is requesting a prior authorization for care prescribed by an ordering practitioner, as is often the case for DME, type the name of the ordering practitioner in the Name field and go to step 12. c. If the individual practitioner referring/requesting the care is associated to the group/clinic showing under Requesting Provider, go to step 8. d. If the practitioner referring/requesting the care is not associated to the group/clinic showing under Requesting Provider, go to step 11.

IHN-CCO Utilization Management and Service Authorization Handbook 24 8. To select a practitioner associated to a group, click the Select Other Provider button.

9. Enter the practitioner’s name in the Name box, and/or select the practitioner from the list.

IHN-CCO Utilization Management and Service Authorization Handbook 25 10. The selected practitioner will then appear under Requesting Provider. Go to step 12.

11. To select a practitioner not associated to the provider currently showing under Requesting Provider, click the Change link in the upper, right-hand corner of the page. You will be returned to the Select Provider option in step 4 and begin again from there.

12. Enter your name and contact information or the information for the referral specialist in your office and click Next. 13. Enter the start and end date of the requested care and select Yes if the service has been scheduled. You will be prompted to enter a scheduled date. 14. Click Find Member to check member eligibility.

IHN-CCO Utilization Management and Service Authorization Handbook 26 15. Enter the member’s name and date of birth. It is best to use the first initial of each name along with the birth date. This will provide all possible plans the member may have.

16. If the member is dual eligible, choose the primary plan. If the secondary plan is selected, the system will default back to the primary with a message.

IHN-CCO Utilization Management and Service Authorization Handbook 27 17. Once the member is selected, click Next.

18. Indicate the type of the request. The Request Type selected will determine which of the following steps you are presented with.

19. If presented, select the Place of Service (type of location where the service will take place) and click Next. If an inpatient type place is selected, you will be prompted to enter the Length of Stay.

IHN-CCO Utilization Management and Service Authorization Handbook 28 20. If presented, select the servicing provider or vendor by clicking on select Provider. When using the search criteria, use the least amount of information possible to give the system a wider search range. By doing this, you will be more likely to find what you are looking for.

21. Be sure to check the provider type to make sure the correct servicing provider is being selected.

22. If the selected servicing provider is out of network for the member, you will be prompted to indicate a reason for selecting a non-participating provider.

IHN-CCO Utilization Management and Service Authorization Handbook 29 23. The servicing provider section will populate once the provider is selected. Click Next to move to the next applicable step. 24. If presented, select the servicing facility by clicking on Select Facility. When using the search criteria, use the least amount of information possible to give the system a wider search range. By doing this, you will be more likely to find what you are looking for.

25. If the selected servicing facility is out-of-network for the member, you will be prompted to indicate a reason for selecting a non-participating facility.

26. The servicing facility section will populate once the provider is selected. Click Next.

IHN-CCO Utilization Management and Service Authorization Handbook 30 27. Select the priority of the request. Keep in mind expedited requests are only for those where waiting the standard time frame (14 days) could place the member’s life, health or ability to regain maximum function in serious jeopardy. Scheduled does not mean expedited. Click Next.

28. Enter the diagnosis and procedure code(s). Once, the first several characters are entered, the system will provide a list of matches to choose from. DME requests should include modifiers to specify if the item is a purchase or rental.

IHN-CCO Utilization Management and Service Authorization Handbook 31 29. Clinical documentation in a PDF format should be attached here and will reduce processing time frame. If unable to attach documentation, indicate the reason in the box.

30. Confirm all information to validate your request and click Submit if complete. If information needs to be changed, click the back button to make necessary corrections.

If an error message occurs, double check the dates of service and/or member eligibility. For assistance, contact the Wizard Assistance line at 541-768-4409.

IHN-CCO Utilization Management and Service Authorization Handbook 32 Be Healthy. Be Happy.

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