The guidelines contain HHS-approved processes and procedures for key program components. Eemer 4 2019.
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Utilization Management UM and Resource Management RM 42 Medical Appropriateness In making UM decisions KP relies on written medical necessity criteria developed in collaboration with practicing physicians.
Utilization management training manual. The healthcare management industry is in a constant state of change. A Core Course. The utilization manager community care managed care or referral decisions will not obligated to know how much physicians and bcbsil after the procedures and qualitative analyses published.
This manual outlines the best practice approaches to utilization review in a manner that is aligned with the Guiding Principles as well as state and federal laws related to utilization review and behavioral health parity. Among the changes are the roles and functions of utilization management UM which has evolved as a system to evaluate medical necessity and appropriateness of care related to optimal outcomes. Utilization review as a process was introduced in the 1960s to reduce overutilization of resources and identify waste.
This course contains updated material. Cms regulatory requirements and utilization management training manual contains more information. A Core Course.
KP HMO Provider Manual 2018 18 Section 4. Oklahoma State University Grand Rounds September 24 2014 Utilization Management. Utilization management UM is a process that evaluates the efficiency appropriateness and medical necessity of the treatments services procedures and facilities provided to patients on a case-by-case basisThis process is run by or on behalf of purchasers of medical services ie insurance providers rather than by doctors.
Utilization Management program goals include. Classroom instructor-led training Virtual instructor-led training Self-directed learning This Training Workbook is not intended for use as a product user guide. Utilization Management Peer Reviewer Training Certificate Course 50 CME Credits 50 CE Credits ABQAURP sub-specialty credits.
Excellence and Ethics in Case Management. This Training Workbook is designed to support the following forms of learning. 2 Applicability Unless otherwise noted this manual pertains to acute mental health services which are defined as inpatient.
April 22 2014. Managed Care 50 Physician Advisor 50 Updated Reviewed. Providers of behavioral health services can use the UM Guidelines to implement a UM program.
Physicians and nurses at Security Health Plan use clinical criteria to make coverage decisions based on. Define UM and explain its origins and purpose. Cabinet for Health and Family Services Department for Medicaid Services.
The Triple Aim for Hospital Case Management. If a requested. How to access the medical director.
The skillset gained popularity within the health insurance industry mainly due to growing research about medical necessity misuse and overutilization of. The Utilization Management Program Manual is a resource for technical assistance to providers to develop and monitor their local UM programs and processes. Basic Manual 5 Amadeus Hellas SA.
Author John Fellonneau Devin Pantess Reviewer Cheryl Hanna Pam Smith Emily Horning HP Management Glenn Jennings SHPS Management. Sud primary care are required to appeal processes. New 2019 Utilization Management Peer Reviewer Training course.
Summary of Utilization Management Process Guidelines and Criteria. O Complex Case Managers RN o Clinical Case Managers RN o Utilization Management Specialists Licensed Practical Nurses LPN o Utilization Management Coordinators. Affiliated providers may discuss a utilization management decision with the Security Health Plan medical director by calling 715-221-9664 or 1-800-548-1224.
Revised 10292015 - 14 - practice video tapes on HIPAA Home Health Ambulance Fee Schedule and numerous Quick Reference Guides On the same page is a link for MEDICARE Electronic ListServs. Do the Right Thing. End-User Training Manual Kentucky Utilization Management Project.
Cabinet for Health and Family Services Department for Medicaid Services. The teams are comprised of. The Holman Group - Provider Manual.
Requests for services are reviewed by Masters-level behavioral health clinicians andor psychiatrists. The utilization review function was initially performed by registered nurses RNs in the acute hospital setting. Sign in to Amadeus using the below entries on the Command Page JI 0001 AA SU - XXXXX JI - action code - Jump In Production 0001 AA Personal Agent Sign details 4 digits and 2 letters SU duty code - XXXXX password 5-8 characters.
Self-directed learning SDL If this course is eligible for self-directed learning demos and exercises throughout this Training Workbook will. Specific care and treatment may vary depending on individual need and the benefits covered. Please seek further information in this Manual for authorization requirements for home health physical occupational and speech therapy prior authorization information.
The materials provided to you are guidelines used by this plan to authorize modify or deny care for persons with similar illnesses or conditions. When it is determined that a person is in need of a physical andor behavioral health service requiring prior authorization a utilization management professional applies the. 60162 TAKE COURSE BUY COURSE Add To Cart BUY COURSE.
2014 Molina Healthcare MedicaidHealthy Michigan Plan Manual Page 2 of 16 Multidisciplinary teams are assigned to a population of members divided by geographic area andor provider group. How to access utilization management criteria. I f you completed the previous version PRIOR to March 16 2019 you may retake.
