Utilization Management Policies
Policy Number and Name
Seaside ensures the availability of, and accessibility to, emergency health care and mental health care services within the service area twenty-four (24) hours-a-day and seven (7) days-a-week.
Seaside ensures that providers are reimbursed for emergency services and care provided to members, until the care results in stabilization of the member and
Seaside staffing structure include staff to perform the following functions; Special Needs Plan (SNP) coordination, data analysis, utilization coordination and training.
Seaside assures that staff coordinates benefits, information, and data collection and analysis for beneficiaries and network providers.
Seaside makes a special effort to coordinate care for Members enrolled in Special Needs Plans, when Members move from one setting to another, such as when they are discharged from a hospital. Without coordination, such transitions often result in poor quality care and risks to patient safety. The Care Transition Process is focused on managing planned and unplanned care setting transitions, identifying unplanned transitions and reducing transitions.
The purpose of this policy is to set forth guidelines for Seaside individuals in managing safe care setting transitions, identifying planned and unplanned transitions, and reducing transitions. Activities include but are not limited to, educating the member and responsible parties and coordinating services for members at high risk of problems with transition and to ensure the Members have a consistent person or unit responsible for supporting the Member and managing care transitions.
The CMS Model of Care defines that care is coordinated for Special Needs Plan (SNP) members through an interdisciplinary care team (IDCT) to address the members’ medical, cognitive, psychosocial, and functional needs. Each Seaside SNP member is assigned to an interdisciplinary care team composed of primary, ancillary, and specialty providers appropriate for the population. The interdisciplinary care team is responsible for overseeing, coordinating, and evaluating the care delivered to assigned members.
The purpose of the Special Needs Program Interdisciplinary Care Team Coordination of Care policy is to provide the specific requirements for defining the team assigned to each SNP member, the roles of the team, and the instructions for how the team will coordinate and evaluate care delivered to assigned SNP members.
Seaside Utilization Management (UM) Program assures the delivery of medically necessary, optimally achievable, quality patient care through appropriate utilization of resources in a cost effective and timely manner.
Seaside UM Program has established processes by which the Plan prospectively, retrospectively, or concurrently reviews and approves, modifies, delays, or denies, based in whole or in part on medical necessity, requests by providers/practitioner of health care services for plan members. These processes ensure that decisions based on the medical necessity of proposed health care services are consistent with criteria or guidelines that are supported by clinical principles and processes.
The Plan policy on the Separation of Medical Services from Fiscal and Administrative Management is distributed via the Internet, written notification to all participating practitioners of the availability of the information on the Provider Portal website and paper copies upon request.
Seaside requires providers, practitioners and staff who participate in UM and Claims processes to sign the Separation of Medical Services from Fiscal and Administrative Management Acknowledgement at least every 2 years.
Seaside UM Program details decision making, turn-around time frames, UM criteria, communication of UM decisions, terminal illness requirements to ensure processing of request for referral authorizations will not interfere with or cause delay in service, or preclude delivery of services. These processes ensure that decisions based on the medical necessity of proposed health care services are consistent with criteria or guidelines that are supported by clinical principles and processes.
Referral Processes are consistent with Seaside UM Program. Decision making, turn-around time frames, UM criteria, communication of UM decisions and terminal illness requirements are followed per the UM Program to ensure processing of request for referral authorization will not interfere with or cause delay in service or preclude delivery of service.
Seaside implements a tracking system for all UM Referrals for documentation/identification of request status.
Seaside tracks referral services ensuring that necessary services were obtained, and follows up on the status of unused or expired referrals to ensure that the member’s ongoing need for care has been met.
When Seaside denies, defers, modifies, delays or terminates a request by a provider for medical services, Seaside notifies Members and Providers in a consistent and timely manner,
Providers are involved in development and/or adoption of criteria used for modifying, deferring or denying requested services. Providers are encouraged to participate in Seaside’s Utilization Management (UM) meetings when UM guidelines (Milliman Care) are discussed.
Seaside, under its delegated agreements with Managed Medi-Cal Primary Plans, does not cover some specialized programs but instead the programs are covered and coordinated through the Medi-Cal fee-for-service (FFS) programs:
The California Children Service (CCS) Program provides medically necessary services and case management for Medi-Cal beneficiaries with: CCS-eligible conditions or diagnoses who meet program eligibility requirements.
CCS services are excluded (“carved-out”) to Medi-Cal. Seaside participating providers are responsible for performing preliminary baseline health assessments and diagnostic evaluations to ascertain evidence or suspicion of a CCS-eligible condition or diagnosis. Potentially eligible members are referred to the local CCS Program for eligibility determination, comprehensive case management and prior authorization of services.
Seaside complies with all CMS requirements related to approved benefits including the use of approved Medicare-certified facilities for performing certain surgical procedures.
Seaside Medi-Cal and Healthy Families participating primary care physicians (PCPs) are required to adhere to the (CHDP) Program requirements by providing early and periodic screening, diagnosis and treatment for Medi-Cal and Healthy Families members under age 21 according to CHDP Program guidelines.
The scope of this policy is limited to case management cases which are the responsibility of the health plan and where Seaside has not been delegated for case management. Seaside complies with requirements of contracted Health Plans and refers case management cases, when applicable to the responsible Health Plan.
Seaside refers Complex Case Management cases to the Primary Plan within the Primary Plan’s set timeframe for identification.
Seaside assists members in obtaining and utilizing community resources and social services through evaluation and identification of the member’s need for social services and community resources.
Seaside has a model of care to manage the delivery of specialized services and benefits for:
Seaside provides reimbursement for Reconstructive Surgery that meets the Primary Plan’s definition.
Seaside does not reimburse for Cosmetic Surgery as defined by the Primary Plan.
For Medicare Advantage members, Medicare generally does not cover cosmetic surgery unless it is needed because of accidental injury or to improve the function of a malformed part of the body. Medicare covers breast reconstruction if a member has had a mastectomy due to breast cancer.