Utilization Management Criteria for Inpatient Services
SWHP Utilization Management Criteria for Inpatient Services and Selected Benefit Coverage Determinations 2012
The SWHP Evidence of Coverage (EOC) [Standard Plan Document (SPD)] is the contract for coverage of the health care services that an individual self-purchased or an employer has purchased for their employees. SWHP provides a variety of benefit plans in order to meet the needs of the purchaser.
Some benefits are required by law to be offered through the Plan. Some services are not offered for various reasons (i.e., not felt to be a good value, or perhaps because the employer does not want an employee to share part of the costs of that care or service through their premium amount). SWHP's primary Utilization Management (UM) Program's purpose is to manage services according to the terms contained in EOC/SPD. The medical necessity of the services is determined by the SWHP medical staff with input from the Member's physicians.
SWHP annually reviews and adopts criteria for use in the UM process. The review process utilizes SWHP physician directors, network physicians and other providers for the Plan. For criteria to be used for 2012 (January 1, 2012 - December 31, 2012), the review included InterQual® evidence-based criteria; internal policies, Healthcare Management Guidelines [target length-of-stay (LOS)], criteria developed and approved during Technology Assessment meetings, and medical coverage policies. SWHP provides the criteria listed above to the physician directors of Scott and White HealthCare's Medical Services Divisions and various contracted network physicians during November/December each year for review and approval for use in the next year. Physicians are able to provide any comments to SWHP Utilization Management for consideration of any proposed changes. All feedback from the physician reviewers is then evaluated by the SWHP Medical Director(s) for consideration of incorporation depending on the issue. The resulting approved final criteria sets and the target LOS are then forwarded to the SWHP UM Committee for review and approval in December of the review year and/or January of the new year, depending on Committee scheduled meetings.
The criteria are used by the UM Staff as a guideline only. All denials of coverage are made by the SWHP Medical Director(s). Any person making decisions on utilization management, including formulary coverage determinations, makes them based only on the appropriateness of care and services. No financial compensation is based on utilization of services or service denials. SWHP does not offer incentives, including compensations or rewards, to Practitioners or other individuals conducting utilization review.
SWHP is concerned that Members receive appropriate services, and monitors for evidence of under use, over use, and misuse. Individual coverage requests are discussed with the individual physicians/providers making the request on behalf of a Member. SWHP UM staff (including Plan Directors) are available by telephone 24 hours/7 days per week at 1-254-298-3088 or (toll free1-888-316-7947 or by appointment for discussion regarding UM and/or coverage determinations, including benefit provisions, guidelines, criteria or the processes used to make determinations. The above numbers are covered afterhours by the SWHP "On- Call" nurse who has access to a Plan Medical Director.
Appeal rights, including expedited appeals, reconsideration rights and/or Independent Review Organization (IRO) options are always provided with any denial that is issued by SWHP. Ability to review the criteria is available to you by fax, phone, mail, email or through an onsite appointment with the Care Coordination Division (CCD) management staff, who can be reached by calling (toll free) 1-888-316-7947 or directly at 1-254-298-3088. Additionally, questions or requests related to any case-specific guidelines utilized in the process of making a medical or pharmacy case determination can be directed to the CCD management for response.
In an effort to improve communication with non-English speaking members, SWHP uses the interpretive services of AT&T. Members do not have to call a special line for this service. When contacting SWHP, Members may notify the CCD staff and/or Customer Advocates of their primary language and the call will be completed with the help of an AT&T interpreter at no charge to the Member. SWHP CCD staff follows established internal SWHP policies related to provision of interpretive services for SWHP members.
SWHP utilizes a toll free TTY number 1-800-735-2988 to assist with communication services for Members with hearing or speech difficulties. The TTY number is listed on the SWHP webpage at www.swhp.org and is also included in your Member correspondence and Member publication materials.
1/2012