Utilization Management Program Form

Overview of Utilization Management Program Utilization Management Review

Utilization Review is a formal evaluation of the coverage, medical necessity, efficiency or appropriateness of healthcare service and treatment plans. Baylor Scott & White Health Plan (BSWHP) and FirstCare Health Plans conduct multiple types of utilization review including but not limited to: • Pre-service Review – occurs in advance of a member obtaining care or services to determine whether or not the proposed services (such as hospitalization) are appropriate and are a covered benefit under the member’s benefit plan. • Urgent Concurrent Review – a review to determine extending a previously approved, ongoing course of treatment or number of treatments which a member is receiving. The review is considered urgent if applying the normal time for review would jeopardize the member’s life, health or ability to regain maximum function. • Post-service Review – occurs after a member has obtained care or services to determine whether or not the care or service received was appropriate and a covered benefit under the member’s benefit plan. Utilization Management Criteria

The Evidence of Coverage (EOC) Benefit Booklet is the contract for coverage of the healthcare services that an individual self-purchased or an employer has purchased for employees. Both BSWHP and FirstCare provide a variety of benefit plans in order to meet the needs of our members. Some benefits are required by law to be offered, and some services are not offered for various reasons (i.e., not felt to be a good value, or perhaps because the employer does not want an employee to share part of the costs of that care or service through their premium amount). The primary purpose of the Utilization Management (UM) Program is to manage services according to the terms contained in the EOC/Benefit Booklet. The medical necessity of the service is determined by BSWHP/FirstCare

medical staff with input from the member’s physician(s). BSWHP and FirstCare adopt criteria reviewed by physician directors, network physicians and other providers for each calendar year. These include InterQual® and other guidelines regarding how long a hospital stay should be (target length of stay (LOS)), for use for medical necessity, for coverage of new technology and medical coverage policies.

Utilization Management Decisions

The criteria are used as a guideline only. All denials of coverage are made by BSWHP/FirstCare Medical Directors. Any person making decisions on utilization management, including formulary coverage determinations, makes them based only on the appropriateness of care and services and according to the terms contained in the EOC/Benefit Booklet. No financial compensation is based on utilization of services or service denials. BSWHP/ FirstCare do not offer incentives, including compensation or rewards, to practitioners or other individuals conducting utilization review. Utilization Management Staff Availability

We are concerned that members receive appropriate services, and monitor for evidence of under-use, over-use and misuse. Individual coverage requests or utilization reviews are discussed with the individual physicians/providers making the request on behalf of a member. BSWHP and FirstCare UM staff are available by telephone 24 hours/7 days per week at 1.254.298.3088 or (toll free) 1.888.316.7947, or by appointment for discussion regarding UM and/or coverage determinations, including benefit provisions, guidelines, criteria or the processes used to make determinations. The above numbers are covered after-hours by on-call nurse with access to a Plan Medical Director. UM staff will identify themselves as a staff member and provide their name and title when calling members or returning calls to members. Language services are provided free of charge to members upon request through bilingual staff or an interpreter to discuss utilization management decisions. TTY (telephone typewriter, or teletypewriter) services are available for persons with hearing or speech difficulties to discuss utilization management decisions by calling 1.800.735.2989.

Appeal of Adverse Utilization Review Decision

A member, a member’s appointed representative or the member’s requesting physician have the right to appeal a final utilization management denial including the right to an independent external review. Appeal rights, including expedited appeals, reconsideration rights, and/or Independent Review Organization (IRO) options as well as instructions about how to file an appeal are always provided with any denial that is issued by BSWHP or FirstCare. The ability to review the criteria is available for members through an on-site appointment with the Health Services Division (HSD) Management who can be reached by calling (toll free) 1.888.316.7947 or directly at 1.254.298.3088.

Additionally, questions or requests related to any case-specific guidelines utilized in the process of making a benefit coverage determination or pharmacy determination can be directed to the HSD Management at the above numbers.