Medicare Advantage HMO Utilization Management and Population Health Management Plan 2021 Approved BCBSIL UM Work Group: November 12, 2020 Approved BCBS QI Committee: November 17, 2020 Blue Cross Medicare Advantage Basic HMOSM Blue Medicare Advocate Health (HMO)SM Blue Cross Medicare Advantage Basic Plus (HMO-POS) SM Blue Cross Medicare Advantage Premier Plus (HMO-POSSM) of Blue Cross and Blue Shield of Illinois 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 Table of Contents Definitions ........................................................................................................................................................................................................... 4 Introduction......................................................................................................................................................................................................... 9 HMO Delegation Oversight ................................................................................................................................................................................ 9 Non-compliance with the Utilization Management .......................................................................................................................................10 IPA Sub-Delegation Requirements and Responsibilities ................................................................................................................................11 HMO Structure, Resources and Goals .............................................................................................................................................................12 MA HMO Committee Structure .......................................................................................................................................................................12 Physician Involvement......................................................................................................................................................................................13 MA HMO Staff ...................................................................................................................................................................................................13 MA HMO Monitoring and Oversight of IPA ....................................................................................................................................................13 Adherence Audits..............................................................................................................................................................................................14 HMO Utilization Management Program Oversight ........................................................................................................................................15 Overview............................................................................................................................................................................................................15 Ensuring Appropriate Utilization .....................................................................................................................................................................15 New and Existing Medical Technology ............................................................................................................................................................16 IPA Delegation Requirements and Responsibilities .......................................................................................................................................16 IPA MA Utilization Management Plan .............................................................................................................................................................16 IPA Physician UM Program Staff Requirements .............................................................................................................................................16 Job descriptions and Staff Training..................................................................................................................................................................18 IPA Utilization Management Program.............................................................................................................................................................18 IPA UM/QI Committee Requirements.............................................................................................................................................................18 IPA UM Tar ge ts .................................................................................................................................................................................................19 Program Scope ..................................................................................................................................................................................................19 Inter-Rater Reliability........................................................................................................................................................................................20 Inter-Rate r Me thodology .................................................................................................................................................................................20 Consistency in the Application of Nationally Recognized Medical Criteria Review .....................................................................................20 Ensuring Appropriate Utilization .....................................................................................................................................................................20 PCP Site Visit Results.........................................................................................................................................................................................21 URO Registration: Illinois Department of Insurance ......................................................................................................................................21 Policies and Procedures....................................................................................................................................................................................21 IPA Utilization Management Requirements ...................................................................................................................................................23 Requirements for UM Decisions ......................................................................................................................................................................23 IPA Behavioral Health Requirements ..............................................................................................................................................................23 UM Criteria for UM Decisions ..........................................................................................................................................................................24 IPA Clinical Criteria for UM Decisions..............................................................................................................................................................24 Notification of Availability of Clinical Criteria .................................................................................................................................................25 Relevant Clinical Information...........................................................................................................................................................................25 Medical Director (MD) Review Requirements ................................................................................................................................................26 Medical Necessity and Benefit Determination ...............................................................................................................................................26 UM Affirmation Statement ..............................................................................................................................................................................26 Page 2 | 55 Access to UM Staff ............................................................................................................................................................................................27 Pre-certification/Pre-Service Documentation ................................................................................................................................................27 Certification/Initial Review Process.................................................................................................................................................................28 Concurrent Review Process..............................................................................................................................................................................29 Skilled Nursing Care ‘Maintenance Coverage Standard’................................................................................................................................30 Hospice ..............................................................................................................................................................................................................30