Medicaid Managed Care - U.S. Senate Special Committee on Aging

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din resulut in inadequate or inappropriate implementation of the crateria.
<strong>Managed</strong> care plans may use a variety of methods to make determinations
of medical necessity. Prior authorization for certain service
concurrent utilization reviews centralized assessment and referral, gatekeeper
screenings, case management and designated provider networks
are all methods used by managed care plans to limit access to services.
Errors in implementation of any of these mechanisms can deny consumer
choice and access to services.
To guard against improper denials, states should establish standards
in their contracts with managed care entities for the process by which
fillredca-necessity determinations are made. For ezample, some managed
care contracts require that personnel who make medical-necessity determinations
have specific credentials. In addition, some states have enacted
relevant statues, which should be referenced in the contract.
At a minimus states should indude in the contract provisions the
process that should be followed.
Mediscal 6icassssy d a ui, shalle made in acwrdence with the folowing
standhnic
(a) decions sbhodd initially he made by the Member and tk Mrembrs
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aringprovider hower the plan may es-bl-b procolbfor wheAs frther
prinsa is necsasry;
(I) when ftrtherapproual iJ netssary, decisions shall be made in a
timel fashion and the plan shall respond within
requem;
_to preasarorizanon
(c) eiions shaU be made by appropiatl trasined mental health profts.
siondss with s tfcienr cinical experiene including experience in treating
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auts with serioses mental illness and children with serious emotional distr-
6~~~~~~et);
(d) the plan shal document how decisionmakrs econsidred the recom-
-omendstw reg-rding mefi-aly ne-sa-y sericsfrom the crSting prof-ssionsass
wael s the desires of the Member and document specific reasons for
overriding rch recommesdations and desires;
(e) determinations of medicaly necessary shall he bas on practce gsadelines
if the plan uses written pratice guidetines), which shal be consistent
with the provisions ofSecrtiosA-D;-
0) criterisf or medicaly necessary services and an practice guideines
used reddstrributed to all providers who participate in the pln an, upon re-
Defining 'Medically Necessary Services to Protect Plan Members
POLICY ANALYSIS BY THE BAZELON CENTER FOR MENTAL HEALTH LA 18