BCBSIL Commercial and Retail HMO Utilization Management and Population Health Management Plan 2021 Approved BCBSIL UM Work Group: November 5, 2020 Approved BCBSIL QI Committee: November 11, 2020 HMO Illinois®, Blue Advantage HMOSM, Blue Precision HMOSM BlueCare Direct HMO SM, Blue Focus Care HMO SM Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association Page 1 of 84 Table of Contents Definitions ................................................................................................................... 5 Introduction ................................................................................................................. 9 HMO Delegation Oversight........................................................................................... 9 Review of Delegated PHM Programs........................................................................... 11 IPA Delegation Requirements and Responsibilities ...................................................... 11 IPA Utilization Management and Population Health Management Plan ...................... 11 IPA Sub-Delegation Requirements and Responsibilities............................................... 12 HMO Structure, Resources and Goals ......................................................................... 13 HMO Quality Improvement (QI) Committee ............................................................... 13 HMO UM Workgroup ................................................................................................. 13 HMO 2021 UM and Population Health Management Plan Goals ................................ 14 HMO Staff .................................................................................................................. 14 HMO Monitoring and Oversight of IPA ....................................................................... 15 Adherence Audits....................................................................................................... 16 HMO Utilization Management Program Oversight ..................................................... 17 Overview ................................................................................................................... 17 Ensuring Appropriate Utilization ................................................................................ 17 Appeals… ................................................................................................................... 17 Standard Appeals ....................................................................................................... 18 Expedited Appeals ..................................................................................................... 19 External Appeals ........................................................................................................ 19 New and Existing Medical Technology........................................................................ 19 Pharmaceutical Management .................................................................................... 19 HMO Population Health Management Program Oversight ......................................... 19 Overview ................................................................................................................... 19 IPA Utilization Management and PHM Structure and Resources ................................ 20 IPA Physician, UM and PHM Program Staff Requirements .......................................... 20 Job descriptions and Staff Training ............................................................................. 22 IPA Utilization Management Program ........................................................................ 23 IPA UM/QI Committee Requirements ........................................................................ 23 IPA UM Targets .......................................................................................................... 24 Complaints/Grievances .............................................................................................. 24 Inter-Rater Reliability ................................................................................................. 24 Inter-Rater Methodology............................................................................................ 24 Consistency in the Application of Nationally Recognized Medical Criteria Review ....... 25 Time Frames Adherence Review................................................................................. 25 UM Timeliness Report ................................................................................................ 25 UM Timeliness Report Calculation Methodology ........................................................ 25 Ensuring Appropriate Utilization ................................................................................ 25 PCP Site Visit Results .................................................................................................. 26 IPA UM and PHM Plan: Supporting Documentation Requirements............................. 26 URO Registration: Illinois Department of Insurance ................................................... 26 Policies and Procedures.............................................................................................. 26 IPA Utilization Management Requirements................................................................ 29 Requirements for HMO Commercial UM Decisions..................................................... 29 UM Criteria for Decision Making ................................................................................ 29 Page 2 of 84 Notification of Availability of Clinical Criteria ............................................................. 30 Services not Meeting Medical Criteria ........................................................................ 30 Medical Director Review Requirements: .................................................................... 30 Relevant Clinical Information ..................................................................................... 31 Medical Necessity and Benefit Determinations .......................................................... 31 UM Affirmation Statement......................................................................................... 31 Access to UM Staff ..................................................................................................... 32 Prospective/Pre-Certification/Pre-Service Process ..................................................... 32 Initial Review: Emergent/Urgent Certification ............................................................ 33 Initial Review-Non-Urgent Precertification ................................................................. 33 Concurrent Review..................................................................................................... 34 Discharge Planning ..................................................................................................... 35 IPA Referral Process ................................................................................................... 35 Required Elements in the Referral .............................................................................. 35 Additional Referral Requirements: ............................................................................. 35 Referral Inquiry Logs: ................................................................................................. 36 Standing Referrals ...................................................................................................... 36 IPA Denial Process for Medical and BH Services ......................................................... 36 Monthly Denial File Audit........................................................................................... 37 Quarterly Denial File Audit ......................................................................................... 38 IPA Behavioral Health Requirements.......................................................................... 38 Urgent Concurrent Denials Termination of Benefits (TOB).......................................... 39 Transition of Care....................................................................................................... 40 Emergency Services .................................................................................................... 40 Maternity Discharge Program .................................................................................... 40 Organ Transplants ...................................................................................................... 41 Out of Area / Out of Network Admissions .................................................................. 41 Out of Area Admissions .............................................................................................. 41 Out of Network Admissions ........................................................................................ 41 Infertility .................................................................................................................... 42 Record Retention ....................................................................................................... 42 HMO PHM Program Strategy, Structure and Resources .............................................. 42 Population Identification...........................................................................................