Section 132.95  Utilization Review

The provider shall have a written utilization review (UR) plan and ongoing activities to assess the appropriateness of Medicaid community mental health services, intensity/level of services, and continued services for the client.  Such services may be subject to utilization management parameters established by the public payer.  These parameters may include, but not be limited to, the volume of service delivered to a single client over a fixed period of time or significant changes in volume of service billed by a specific provider.  The written UR plan shall address:

a)         The methods and procedures for performing and recording individual case reviews by persons not involved in providing services to the clients whose records are reviewed;

b)         The authority and functions of the individual case review designated unit, which may be:

1)         A representative committee, chaired by a QMHP, and including QMHPs, MHPs, and RSAs; or

2)         A QMHP;

c)         Procedures describing the method for selecting cases for quarterly case review and the procedures for reviewing 10 percent of the clients served under this Part annually;

d)         Procedures to ensure that the review includes and summarizes the client's progress over the previous 90 days;

e)         Policies and procedures for documenting and reporting individual case reviews findings, determinations and recommendations to the supervising QMHP and, if applicable, the billing department;

f)          Procedures for appeal by clients and staff affected by the UR decisions with which they disagree;

g)         Provisions for ensuring confidentiality of individual case reviews, determinations, results and/or recommendations in accordance with the Confidentiality Act and HIPAA; and

h)                  Procedures for following up on case review recommendations.

(Source:  Amended at 31 Ill. Reg. 9097, effective July 1, 2007)