Utilization Management

Buckeye Health Plan is responsible for determining medical necessity for services and supplies requested for its members. To be successful in submitting a request for prior authorization of Ohio Medicaid Services, please include documentation that supports medical necessity.

The documentation you provide will:

• Address generally accepted medical practice standards (standards based on credible scientific evidence published in peer-reviewed medical literature recognized by the medical community)
• Document the clinical appropriateness of the service
• Provide the plan of care established between you and the Medicaid benefit recipient. This should include any documentation fo things tried and failed and specially the plan of care you have established for the patient.
• Be the lowest cost service that is appropriate to treat the healthcare needs of the Medicaid recipient
• And, if the services are being requested to diagnose an issue, the clinical documentation should include how the service results would inform the Medicaid recipient’s plan of care

As you should know medically necessary services would not benefit anyone financially, be solely for member or provider convenience, or experimental and/or investigational. Medically necessary services should be provided to support the Medicaid recipient’s physical and behavioral health outcomes

Reference: OAC rule 5160-26-03 Medically Necessary Covered Services, for members covered, and not covered, by early and periodic screening, diagnosis and treatment (EPSDT), is defined as: “coverage for procedures, items, or services that prevent, diagnose, evaluate, correct, ameliorate, or treat an adverse health condition such as an illness, injury, disease or its symptoms, emotional or behavioral dysfunction, intellectual deficit, cognitive impairment, or developmental disability, and without which the person can be expected to suffer prolonged, increased or new morbidity; impairment of function; dysfunction of a body organ or part; or significant pain and discomfort”.

Notifications are communications to Buckeye Health Plan regarding a member’s admission to or discharge from a hospital. Admission notification can be submitted on Buckeye Health Plan website under the Medicaid PA check tool or by faxing admission information to 866-709-1109 or 866-786-1039. This form can be found on our website in the Forms section. Timely notification of the members discharge date must be provided.

Concurrent Review

Concurrent review is initiated as soon as Buckeye’s utilization review nurses are notified of the admission and initial clinical information is submitted. Subsequent reviews are based on the severity of the individual case, needs of the member, complexity, treatment plan and discharge planning activity.

• Buckeye ensures the oversight and evaluation of members when admitted to hospitals, Long-term Acute Care facilities, rehabilitation centers, and skilled nursing facilities (SNF). This oversight includes reviewing continued inpatient stays to ensure appropriate utilization of health care resources and to promote quality outcomes for members.
• Buckeye provides oversight for members receiving acute care services in facilities mentioned above to determine the initial/ongoing medical necessity, appropriate level of care, appropriate length of stay, and to facilitate a timely discharge.

The authorization will occur concurrently based on guidelines for appropriateness of continued stay to:

• Ensure that services are provided in a timely and efficient manner.
• Make certain that established standards of quality care are met.
• Implement timely and efficient transfer to a lower level of care when clinically indicated and appropriate.
• Complete timely and effective discharge planning.
• Identify referrals appropriate for case management (CM) or quality-of-care review.
• Identify cases appropriate for follow up by the CM/service coordinator.

Concurrent review decisions are made utilizing the following criteria:

• Ohio Administrative Code (Ohio Department of Medicaid rules)
• Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)
• Interqual® Level of Care Criteria
• Centene (Buckeye Health Plan) clinical policies

These review criteria are utilized as a guideline. Decisions will take into account the member’s medical condition and co-morbidities. The review process is performed under the direction of the Buckeye’s medical director.

Frequency of review will be based on the clinical condition of the member. The frequency of reviews for extension of initial determinations is based on the severity/complexity of the patient’s condition, necessary treatment and discharge planning activity, including possible placement in a different level of care. Clinical information is requested to support the appropriateness of the admission, continued length of stay, level of care, treatment and discharge plans.

1. Initial clinical information is submitted by the provider and reviewed at level 1 per the BHP review nurse.
   • If unable to certify or approve the requested level of care, a request for additional information within an appropriate timeframe is made. If submitted within the timeframe requested, this information will be considered with the initial information.
     • If criteria is met, an approval letter is generated with notification of next review date.
     • If criteria is unable to be met, it is submitted to a medical director for secondary review.
     • If the medical director determines the stay is not medically necessary, notification is made to the facility and a denial letter is issued.
2. In the event of an adverse determination, a physician involved with the patient’s care or physician advisor from the facility may request a Physician to Physician (peer to peer) discussion with a medical director at BHP by calling Utilization Management at 866-246-4356, extension 24084, or by secure email to Buckeye_peer_to_peer_notification@Centene.com within five (5) calendar days of receiving the notice of determination.
3. Post discharge requests - Request for Review of Inpatient Status.
   • All post-discharge requests for review must be submitted with an explanation as to reason for a retrospective review, i.e., unable to know, retrospective eligibility type situations.
     • If the request meets the need for retrospective review, a UM nurse will review and follow the process and notification (Step 1) of determination within 30 days.

Buckeye will:

1. Offer an External Medical Review (EMR) to a provider who is unsatisfied with the Buckeye Health Plan's (Buckeye) decision to deny, limit, reduce, suspend, or terminate a covered service (i.e., those specified in Appendix B, Coverage and Services) for lack of medical necessity.
   
   Note* Services that are denied for reasons other than lack of medical necessity (e.g., the service is not covered by Medicaid) are not subject to EMR.
   
   
2. Use the individual or entity provided by ODM to perform the EMR at no charge to the provider.
3. Ensure the EMR process will not interfere with the provider's right to request a peer-to-peer review, or a member's right to request an appeal or state hearing, or the timeliness of appeal and/or state hearing resolutions.
4. The provider has a right to an EMR review within 30 calendar days after the provider’s receipt of Buckeye’s initial decision.
5. Buckeye will issue a written decision to the provider within the following timeframes: 
       a. for EMR requests associated with expedited service authorization decisions:
           i.   within 24 hours from Buckeye’s receipt of the external medical review.
           ii.   Buckeye will notify the provider verbally of the decision within that timeframe.
       b. for EMR requests associated with standard service authorization decisions:
            i.   within 30 calendar days from the Buckeye’s receipt of the request for an EMR
       c.  for EMR requests associated solely with provider payment
           (i.e., the service was already provided to the member):
           i. within 60 calendar days from the Buckeye's receipt of the request for EMR
6. For reversed service authorization decisions, Buckeye will authorize the services promptly and as expeditiously as the member's health condition requires, but no later than 72 hours from when Buckeye receives the EMR decision.