Medical Management Program Description

New West’s Medical Management Program has been developed in order to achieve the following goals:

• To assure that care is delivered in the appropriate setting using appropriate resources.
• To assist in assessment and coordination for alternative levels of care or treatment settings consistent with the delivery of quality care.
• To continually monitor, evaluate, and optimize health care resource utilization in collaboration with participating providers.
• To follow the patient throughout the health care delivery system through care coordination and case management activities.
• To monitor Quality Improvement activities as reported to and by the Quality Improvement Committee.
• To educate members, physicians, hospitals, and other ancillary providers about high quality, cost effective management of the delivery of health care services through such measures as Best Practices and Practice Guidelines.
• To comply with state and federal regulatory requirements through development and implementation of medical management programs and the monitoring of data.

The Director of Medical Services shall be responsible for the administration of the Medical Management Program. The Director shall report Medical Services activities to the Medical Director and the Chief Executive Officer. These activities are then reported to the Medical Steering Committee. Activities of the Medical Steering Committee ultimately are reported to the Board of Directors. The Board of Directors of New West has ultimate responsibility for the quality and the cost effectiveness of the delivery of health care services to its members, whether services are arranged for or directly provided by a contracted entity or provider. The Board of Directors receives, at a minimum, a quarterly summary of Medical Services activities.

The Medical Steering Committee is formally established by the Board of Directors and is chaired by an elected member of the committee. The committee is scheduled to meet monthly. Additional meetings may be scheduled as required. Minutes of the meetings are maintained on file by New West.

An annual Program Evaluation is prepared and submitted to the Board of Directors which includes comprehensive evaluation of the effectiveness of the Medical Management Program.

Medical Steering Committee membership includes, but is not limited to, the following:

• Chief Executive Officer
• NW Medical Director
• Director of Medical Services
• Quality Improvement Director
• Plan Participating Physicians
• Participating Pharmacist
• Ad hoc members, as required

Voting privileges will be given to the Medical Director and Plan Participating providers. The Plan staff members do not have voting privileges.

Specific responsibilities of the Medical Steering Committee are to:

• Annually review, revise and adopt the Medical Management Program.
• Review and approve the annual Medical Management Program Evaluation.
• Develop and revise clinical criteria, policies, guidelines and programs.
• Review and approve utilization and quality indicators for monitoring.
• Recommend cost and utilization controls.
• Review and evaluate provider utilization and compliance issues.
• Review and approve providers requesting participation in the Plan.
• Review and approve recommendations made by the Pharmacy and Therapeutics Committee.
• Review and approve the annual Quality Improvement Program, Quality Improvement Work Plan and Quality Improvement Program Evaluation.
• Review and approve activities of the Quality Improvement Committee.
• Review and make recommendations regarding new technology and application of existing technology for new uses.

All patient records, reports, committee minutes, audits, and documentation of Medical Services Department activities are considered confidential. Records, reports, minutes, audit results, and other Medical Services Department documentation are presented to the Medical Steering Committee as appropriate. All material will be stamped “Confidential”, per the Peer Review Act. Distribution of any report is restricted to the following Plan staff when the staff member has a need-to-know:

• Medical Director
• Medical Steering Members
• Quality Improvement Manager
• Board of Directors

Member files are maintained in the Medical Services Department. Each file is labeled with the member’s name. All utilization records, not maintained in the computer system, and all written member correspondence are kept in a locked and secure Member Medical File. All employees who have the need to access the member information must sign a confidentiality agreement.

Medical Services activities are coordinated and conducted by Medical Services staff under the direction of the Medical Director and the Director of Medical Services. Medical Services staff includes Nurse Care Managers (Registered Nurses) as well as Medical Services Specialists (Licensed Practical Nurses).

Responsibilities

1. Medical Director

The Medical Director is responsible for monitoring the implementation of the
Medical Management Program and assuring that corrective actions are taken
when problems occur.
This responsibility includes:

• Reviewing all cases that do not meet medical necessity criteria.
• Reviewing all requests for non-covered benefits and services.
• Having the final decision on all cases that require medical necessity review, pending the appeal mechanism.
• Reviewing all quality of care or potential quality of care issues.
• Reviewing issues and giving recommendations regarding grievances and appeals.
• Educating providers about the policies and procedures of the Plan.
• Direct involvement in all HEDIS studies and reviews.
• Being a resource to the Medical Services Departmental staff regarding clinical information or clarification of appropriate/established medical practices.
• Speaking with providers whenever there is a need to clarify medical service coverage determinations made by New West.




2. Plan Participating Providers

Plan participating primary care providers are encouraged to take the lead in coordinating medically necessary healthcare services for New West members in accordance with their plan benefit structure. For services not covered by New West, the primary care provider should take responsibility in coordinating with community agencies, or request assistance from New West Case Management to assist with care coordination.

In addition, participating New West providers are encouraged to obtain or assist the member in the process of obtaining prior authorization for services requiring prior authorization. Failure to obtain required prior authorization may result in a denial of claims for those services requiring prior authorization. The hold harmless clause for members will be invoked, as appropriate, for any denied coverage for failure to authorize or for services which are determined to not meet criteria for medical necessity or appropriateness.

3. Nurse Care Managers

The Nurse Care Manager is responsible for obtaining and reviewing all necessary clinical information, using available clinical guidelines/criteria and clinical expertise to determine the medical necessity of care. The Medical Director is also utilized as a resource for the Nurse Care Managers regarding clinical information or clarification of appropriate/established medical practices.
This process is applied in performing:

• Prior authorization of planned admissions.
• Authorization and clinical review of emergency admissions.
• Prior authorization of targeted ambulatory services.
• Concurrent and retrospective reviews.
• Discharge planning and complex case management.
• Education, training and ongoing support to members and providers.
• Education to members regarding in-network and out-of-network benefits.
• Supporting the Quality Improvement process through the identification of potential quality of care issues and gaps in current workflows and processes.
• Care coordination for members who have complex healthcare needs across the continuum of care who would benefit from this service.
• Identification and reporting of any potential fraud, waste, or abuse.




4. Medical Services Specialists

The Medical Services Specialist is responsible for providing clinical support to the Medical Services Department processes by obtaining, documenting, and analyzing medical information obtained from healthcare providers and members regarding requests for inpatient admissions, medications, outpatient procedures, equipment and other healthcare services for eligible members. The Medical Services Specialist is responsible for being available to assist with member medical needs via the phone que during regular business hours.

5. Participating Hospitals

Participating hospitals are encouraged to verify prior authorization by contacting the Medical Services Department prior to providing any service requiring prior authorization. They are also encouraged to verify the member’s eligibility prior to rendering care for non-emergent services.

If the hospital contacts the Medical Services Department to verify prior authorization for a service has been completed and finds that one has not been obtained, the Nurse Care Managers will assist the hospital by contacting the admitting physician to coordinate the prior authorization process.

Hospital personnel are responsible for notifying Medical Services within one business day of all emergent inpatient admissions of New West members.

Hospital discharge planning personnel must work with the Nurse Care Managers to arrange for and implement all discharge planning for a patient’s transition to a less acute level of care or to coordinate case management activities.

6. Members

All members are responsible for seeking medical services in accordance with their New West Evidence of Coverage and Benefits Booklets.

1. Quality Improvement Department

The Medical Services Department works with the Director, Quality Improvement (QI) concerning audits and focused studies initiated by the QI Department, and also concerning results/issues regarding activities arising from the QI Annual Work Plan. The QI Director trains all Medical Services personnel regarding QI procedures, and other related QI activities as needed. Medical Services personnel are responsible for reporting potential quality of care issues to the Medical Director and the QI Director. Examples of potential quality of care issues may be:

• Unexpected death of a member.
• Under / over utilization of healthcare services.
• Any case management issue identified relating care coordination for members with chronic conditions.
• Immunization compliance for children, adolescents and Medicare eligible members.
• Member complaints regarding quality of care rendered to them.




2. Provider Services Department

The Medical Services staff communicates with the Provider Services staff as needed to address medical management issues that require combined efforts. Some of the issues that require combined efforts include, but are not limited to the following:

• Contractual issues and negotiations for health care services as needed.
• Provider newsletters and mailings.
• Network composition and size.
• New Medical Services policies and procedures.
• Provider non-compliance.
• Provider educational needs.
• Provider satisfaction.




3. Customer Services Department

The Medical Services will work with the Customer Service Department relating to any Medical Services issue that may require assistance in member communication, or the need for pre authorization or access to medical services. Examples of these issues may be:

• Customer Services will contact / assist members with explanation of benefits relating to requested or rendered healthcare services.
• Customer Services will assist members to resolve issues relating to claims payment.
• Customer Services will communicate any new policies or procedures as appropriate.
• Customer Services will assist members to locate plan participating providers per the member’s request.

The Medical Services Department is responsible for performing the following services:

1. Prior Authorization of Services

Prior authorization of services includes review of member eligibility, benefits, medical necessity, and appropriateness of services and level of care. In addition, any potential quality of care issues are identified and in / out of network benefit education is addressed. Services requiring prior authorization include, but are not limited to:

• All services listed under the Prior Authorization section or the member’s Evidence of Coverage or Benefits Booklet document.
• Non-emergent transportation.
• Planned inpatient admissions, including: rehabilitation, skilled nursing, mental health.
• Organ Transplants - evaluation, transplant and post-transplant care.
• Any potential cosmetic, experimental or investigational service.




2. Notification of Emergency Admissions

Notification for Emergency admissions should be provided by the participating provider within one business day following admission. Members / family are also encouraged to notify the Plan of any emergent / urgent admission so as to provide opportunity for discharge planning and Case Management services as needed. If the member has a primary care physician, they should be notified by the participating provider as soon as possible to permit the primary care physician to become involved in the member’s care.

3. Concurrent Review

Concurrent review is initiated for all admissions immediately upon the Plan’s notification of an admission. The review may be conducted by telephone, faxed information, or by a combination of both. The Nurse Care Manager checks eligibility and benefits, and obtains and reviews necessary clinical information to determine the medical necessity and appropriateness of service and level of care. The Nurse Care Manager also identifies Case Management needs and assists in arranging for timely discharge. Quality Improvement indicators are utilized to identify potential quality of care issues.

Concurrent review for medical necessity, appropriateness of service, and level of care for continued inpatient stays or services is conducted as frequently as the patient’s condition or intensity of service requires. Cases that do not meet medical necessity criteria, or that have questions relating to benefits or appropriateness or quality of care are referred to the Medical Director for review and determination.

4. Case Management

New West’s case management is a continuous process of identifying individuals at high risk for problems associated with complex health care needs. This includes assessing opportunities to coordinate care, control costs, and manage a member’s full spectrum of care in order to optimize outcomes. The Plan uses a team approach, including the primary care provider, attending physician, home care agencies, facility discharge planners, physical therapists, social workers, nurses, members/family or caregivers and community agencies, as appropriate.
Case Management is initiated when a potential high risk member is identified through: the prior authorization process, Medicare Advantage Health Risk Assessment information, member inquiries regarding complex benefits, referrals from providers or from claims information. Key to New West’s case management process is early identification of potential or actual health care needs, member and provider involvement, and coordination of care across a variety of alternative level of care settings.

5. Retrospective Review

New West reserves the right to retrospectively review any covered service. Retrospective review may be performed on services that are listed as requiring prior authorization when a claim has been received without documentation of an authorization being completed. Retrospective review may also be conducted on prior authorized services in order to match the services authorized to the charges received. Inpatient services that have not been prior authorized are reviewed retrospectively for benefit application, medical necessity, appropriateness of setting, and length
of stay, and are subject to eligibility requirements at the time the services were provided. Medical necessity determinations will be made based upon medical records submitted for review.

6. Discharge Planning

Discharge planning is an essential component of New West’s medical management and case management process. Discharge planning will be considered for all inpatient admissions to ensure cost effectiveness and continuity of medically necessary care. The process will be initiated at the time of prior authorization or admission to a facility. The Nurse Care Manager will coordinate
the member’s medical services with the attending physician, primary care provider and/or the discharge planning personnel at the facility. The Nurse Care Manager collaborates with the hospital discharge planners and admitting/attending physicians regarding facilitating the patient’s transition to a less acute level of care. Discharge planning may include educating the patient
and family/caretakers about the patient’s discharge needs. The Nurse Care Manager will interact with or recommend appropriate social agencies to assure maximum utilization of community resources.

7. Evaluation of Utilization Patterns

The Medical Services Department will review inpatient and outpatient utilization data to evaluate the appropriateness of member and physician utilization patterns, including under and over utilization of services.

8. Claims Review

The Medical Services Department will review claims as necessary for accuracy, benefit application and payment, medical necessity, appropriateness of charges,
and appropriate authorization.

9. Identification of Potential Quality of Care Issues

The Medical Services Department will assist in the identification and on-going monitoring of potential quality of care issues, using adverse outcome indicators
and reporting concerns to the Quality Improvement Director.

10. Medication Therapy Management Program

New West Health Services provides a Medication Therapy Management Program (MTM) for eligible Medicare Advantage beneficiaries. The goal of the medical management initiative relating to the MTM will be to optimize therapeutic outcomes through improved medication use, and to reduce the risk of adverse events, including adverse drug reactions in certain high risk beneficiaries. Beneficiaries that will be targeted for the MTM program are those individuals who (i) have two or more of the targeted chronic diseases, (ii) are taking at least five covered Part D drugs, and (iii) are likely to incur annual costs for covered Part D drugs in excess of $4000 for 2007.

Medical management interventions that may be employed include: prior authorization of targeted drugs; drug limitations; and case management.

The Medical Services Department and Medical Director apply clinical guidelines, criteria, and reference tools that are formally adopted by the plan’s Medical Steering Committee to assist in determining medical necessity and appropriateness of care. Reference tools, criteria, and guidelines include, but are not limited to:

• Milliman Care Guidelines.
• Hayes, Inc. Criteria.
• Member Outline of Benefit Coverage.
• Medicare Guidelines.
• CareMark Prior Authorization Medical Necessity Criteria for Drugs.
• American Society of Addiction Medicine (ASAM) Patient Placement Criteria for the Treatment of Substance-Related Disorders.

General information regarding criteria for appropriateness of medical services is available from the Medical Director upon written request from participating providers. Providers are informed of this right via notification in the Provider Manual and periodic notification within the Provider Newsletter.

All Nurse Care Managers and Medical Services Specialists performing prior authorization or medical review will be audited on a regular basis in order to ascertain the consistency and accuracy of application of the established medical review criteria.

Each Nurse Care Manager or Medical Services Specialist will review requests for medical procedures, devices or drug system overrides against established criteria. If there are no established criteria and in the nurse’s judgment the procedure is new, the Nurse Care Manager or Medical Services Specialist will discuss the case with the Medical Director. The Medical Services Specialist or Nurse Care Manager will obtain case details and will obtain literature pertaining to the requested service from the requesting provider.

Once all the available information is obtained from the requesting provider, the case will be formally referred to the Medical Director for review. The Medical Director will establish if the requested service is a new technology. The Medical Director will research the new technology, utilizing such tools as medical literature searches or Expert Panel of providers as needed. This will occur in a timely fashion, based upon the medical condition of the member and the urgency of the treatment.

Once a determination is made, the New West Medical Director will document the results and the final decision will be communicated in writing to the member and the requesting provider, as appropriate. A formal Medical Policy may be drafted and forwarded to the Medical Steering Committee for adoption into the New West Medical Policy Manual.

Medical Services Department Policies and Procedures
New West’s policies and procedures meet all contractual obligations with the State of Montana, Centers for Medicare and Medicaid Services (CMS), federal laws and regulations. All policies and procedures related to clinical decision making are approved by the Medical Steering Committee.

1. The patient’s treating provider and / or the member may initiate the prior authorization process by calling, faxing, or mailing the Medical Services Department with the request.
1. Planned admissions

The admitting physician or member should provide the prior authorization number to the facility in order to facilitate billing prior to admission to that facility. All verifications are subject to Plan benefit limitations, exclusions, and eligibility of the member at the time services are rendered.

2. Emergency Admissions

The Plan’s Medical Services Department should be notified within one business day following an emergency admission.

3. Ambulatory Services

The Plan requires prior authorization for certain ambulatory services, as outlined in the Prior Authorization section of the member’s Evidence of Coverage or Benefits Booklet documents.

4. Surgical Procedures

All surgical procedures noted in the Prior Authorization section of the member’s Evidence of Coverage or Benefits Booklet, regardless of the place of service, must be prior authorized. If the attending physician in an individual case believes a procedure generally performed on an outpatient basis should be performed on an inpatient basis, the Medical Director reviews the request, makes a determination, and documents his/her decision. This decision is communicated to the member and provider in writing.

The Nurse Care Manager evaluates the medical necessity and appropriateness of location, service and level of care, using medical record information and, if appropriate, consultation with the patient’s primary care and/or attending physician.

If the Nurse Care Manager or Medical Services Specialist is not able to authorize proposed care based on the available information, the case is referred to the Medical Director for review, further information gathering, and determination of medical necessity.

The Medical Director may consult with appropriate physician consultants or pharmacists, as necessary, in order to make a determination of medical necessity.

2. Denials of Coverage for Medical Services

When the Nurse Care Manager or Medical Services Specialist is unable to authorize proposed care, the Medical Director must review the authorization request and any available clinical information, prior to the issuance of any denial based on established criteria from a lack of medical necessity, the request being deemed experimental / investigational or for any other non-administrative reason. A decision to deny authorization based on medical necessity can only be made by the Medical Director. As a part of this review, the Medical Director may discuss
the case with the attending physician.

Administrative denials (usually for the lack of coverage or eligibility) that occur during the medical management process, for reasons other than medical necessity, do not require review by the Medical Director. The Medical Services Specialist or Nurse Care Manager may make administrative denials for requests for authorization when there is insufficient information to make a determination and there has been reasonable effort demonstrated to obtain the necessary information.

During a retrospective review of claims for non-authorized care, a denial may also be issued for the following reasons:

• The services were a non-covered benefit. When the benefit is subject to interpretation, the case must be reviewed by the Medical Director.
• The patient was not eligible for benefits at the time care was provided.
• The care was not medically necessary. When medical necessity determination is required, the case must be reviewed by the Medical Director.



During a retrospective review of claims for authorized care, payment for services may be denied if it is found that information previously given in support of the
authorization was erroneous or the actual care provided was inconsistent with the authorization and not medically necessary as determined by the Medical Director. At all times and in all communications, the distinction that a denial is a coverage determination and not a treatment decision or recommendation must be clearly maintained.

Notwithstanding a denial of coverage, a member may choose to assume financial liability for non-authorized services. A denial is communicated within 24 hours of the decision to all involved parties and a written notification mailed. The written notification is sent to the following:

• The member or the member’s authorized representative, if the member is a minor or an incompetent adult.
• The facility, if applicable.
• The requesting physician or ancillary provider.

The written notice includes the specific reason for the denial, the applicable language from the section of the member’s Evidence of Coverage/Benefits
Booklet that supports the denial, and mechanisms for appealing the decision.
Denials relating to Medicare Advantage members will follow all established
policies and requirements put forth by CMS.

3. Appeals Process

Appeals are handled in accordance with the plan’s appeals process. The appeals process is consistent with the New West appeals policy and meets applicable state and federal laws and regulations.

All Medicare Advantage member appeals will be handled in accordance with CMS requirements.

The Pharmacy and Therapeutics Committee function has been delegated to Express Scripts, Inc. the New West Health Services Pharmacy Benefit Manager. The areas of medical management that have been delegated to Express Scripts include recommendations regarding additions or deletions to the formulary and medical necessity criteria development.

Oversight review regarding committee participation and credentials will be made annually with final approval by the Medical Steering Committee.

The Medical Management Program will be reviewed and revised at least annually by the Medical Steering Committee.