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DELAWARE HEALTHY CHILDREN PROGRAM (DHCP) 9

Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

Utilization Management

The MCO must have written utilization management policies and procedures that include protocols for denial of services, prior approval, hospital discharge planning, physician profiling, and retrospective review of claims. As part of its utilization management function the MCO must also have processes to identify utilization problems and undertake corrective action.

The MCO will develop and maintain a Utilization Management Committee to oversee utilization management decisions. The committee must include membership by individuals representative of the organization's provider network. The committee must also participate in the development of utilization management policies and procedures. The MCO must also ensure that it has sufficient/appropriate staff and resources to perform utilization management functions.

In addition, the State operates a Drug Utilization Review system that provides for prospective and retrospective reviews with oversight provided by a nine- member board. The prospective review generates alerts for medication problems at the time that the prescription is dispensed. The retrospective review monitors beneficiary compliance and overall prescribing/dispensing patterns.

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Page 9

Official source

DELAWARE HEALTHY CHILDREN PROGRAM (DHCP) 9

Transmittal # DHCP SPA #5 Approval Date July 28, 2009 Supersedes Transmittal # DHCP SPA #4 Effective Date April 1, 2009

Utilization Management

The MCO must have written utilization management policies and procedures that include protocols for denial of services, prior approval, hospital discharge planning, physician profiling, and retrospective review of claims. As part of its utilization management function the MCO must also have processes to identify utilization problems and undertake corrective action.

The MCO will develop and maintain a Utilization Management Committee to oversee utilization management decisions. The committee must include membership by individuals representative of the organization's provider network. The committee must also participate in the development of utilization management policies and procedures. The MCO must also ensure that it has sufficient/appropriate staff and resources to perform utilization management functions.

In addition, the State operates a Drug Utilization Review system that provides for prospective and retrospective reviews with oversight provided by a nine- member board. The prospective review generates alerts for medication problems at the time that the prescription is dispensed. The retrospective review monitors beneficiary compliance and overall prescribing/dispensing patterns.