	Network Administration

Introduction

Administration and Management

Service Delivery Administration Standards

Service Standards

PA-NET 7: Utilization Management

The network conducts utilization management to ensure that its services are appropriate, represent the best value for the purchaser and consumer of service, and meet the needs and preferences of service recipients.

PA-NET 7.01

The utilization management process is continuous and includes the use of common criteria across the network for admission, service provided, length of service, level of care, and discharge decisions.

PA-NET 7.02

Utilization management criteria are available upon request to network service providers, and the network identifies the source or sources of the criteria.

Interpretation: Networks manage utilization in several ways; however, in all cases, networks need criteria that help guide service delivery decisions.

Utilization management criteria should be applied to help inform clinical judgments – not to substitute for clinical judgments – and to protect the interests of both service recipients and purchasers. This does not mean that all decisions must conform to criteria to be considered appropriate. For example, the preferences of individual clients are also an important factor in the decision-making process, and in the case of clients whose services are voluntary, the preference of a client for lower intensity care than that indicated by the criteria may result in an appropriate placement decision that is at variance with the criteria. The criteria may protect recipients from being placed in services that are more restricted than needed and being denied access to services that meet the recipient’s need for more intensive or lengthy services. Also, the criteria may protect the purchaser from paying for services that are more expensive than needed.

Sources for utilization criteria commonly include expert panels or bodies, and documented evidence. In many cases the purchaser will provide criteria. If the network develops its own criteria, it should rely on persons with the credentials and experience to provide the direct services to develop the criteria. The network may use nationally recognized criteria, such as the addictions-treatment placement criteria developed by the American Society of Addiction Medicine (ASAM), it may develop its own criteria according to nationally recognized practice guidelines, or it may use criteria identified by the purchaser. In any case, the network needs a formal process of approving the criteria it uses and making the criteria available to those applying the criteria, including direct service providers.

PA-NET 7.03

Utilization management personnel are qualified as follows:

personnel conducting utilization reviews have appropriate experience and training;
supervisors of service authorization personnel have appropriate experience and possess relevant credentials;
medical necessity decisions are made by licensed and qualified clinicians; and
appeals are reviewed by persons who are licensed or credentialed to provide the service under review.

PA-NET 7.04

Networks that provide centralized service authorization include a designated care manager or centralized care management unit to ensure that service planning is continuous, comprehensive, and integrated.

NA The network does not provide authorization for services.

PA-NET 7.05

Utilization management includes, as appropriate to the services being provided, a regular review of data related to:

appropriateness of admissions and authorization decisions, if authorizations are part of network services;
intake and referral processes;
service planning and service delivery milestones; and
intake and discharge data including length of service per event, number of encounters per event, and number of re-admissions, as applicable to the service being provided.

Interpretation: Networks manage utilization in several ways; however, in all cases, networks need criteria that help guide service delivery decisions.

PA-NET 7.06

The network management entity conducts:

a quarterly review of its authorization and placement decisions for all network services that includes a ten percent sample of open and closed cases, including a representative sample of high-risk cases; and
at least annually a review of ten percent of contractor case records.

PA-NET 7.07

Managing entities that conduct preauthorization and reauthorization for services:

respond to requests for authorization, initial screening, or reauthorization according to standards for timeliness that are in proportion to the urgency of the request;
provide a 24-hour response line when responsible for authorization of crisis, emergency, or urgent care; and
record the reason for placement decisions and relate this decision to criteria.

Interpretation: When network managing entities provide these initial or continuing authorizations, these more intensive utilization management activities are usually provided as a core network service. See the interpretation for PA-NET 4.02 for a discussion of criteria.

NA The network does not provide pre- or continuing authorization for services.

PA-NET 7.08

If authorization for services is denied the network management entity:

informs the person or service provider requesting the authorization of the reason for the denial;
relates the reason for the denial to the criteria used for making authorization decisions; and
informs the client or service provider of the right to appeal the denial of authorization and the timeframes for the appeal.

Interpretation: As used in PA-NET 7.08, the term “appeal” refers to a request for a review and reconsideration of the denial. It does not imply any suggestion of wrongdoing or failure to follow criteria or procedures. This is in contrast to a grievance, which means that the person filing the grievance believes that their rights have been violated or that procedures have not been followed. Appeals can be made by the service recipient or his/her service provider.

PA-NET 7.09

Timeframes for appeals of denials of service authorizations:

ensure that appeals are reviewed and the results communicated in time for the service recipient to enter or continue services without interruption; and
vary according to the urgency of the issue.

QUICK JUMP TO


	PURPOSE: Network services are delivered to a defined population through an integrated network of providers with the goal of ensuring optimal access, quality of care, and consumer satisfaction.

RELATED FILES


	SERVICE One or more organization-operated programs or activities that have a common general objective and deploy the organization's material and human resources in a planned and systematic manner. An organization that publicly promotes or identifies itself in writing as offering a service, is licensed to deliver a service, assigns personnel and/or space to a service, or allocates financial resources to a service is considered to offer that service.


	QUALITY In this context, the extent to which contemporary and generally recognized standards for professional practice are met and exceeded, and desirable service outcomes achieved.


	CONSUMER The individual, family, group, or community that seeks or receives services.


	SERVICE RECIPIENT The individuals, groups, organizations, or communities that use, receive, or benefit from programs and services. Service recipients can include consumers, patients, family members, legal guardians, advocates, public/private organizations, employers, and purchasers. All are regarded as significant stakeholders served in a variety of agencies and practice settings.


	CRITERIA Systematically developed, objective, and quantifiable statements used to assess the appropriateness of specific decisions, services, and outcomes.


	CASE A general term used to designate clients (including individuals, families, and groups) served by an organization for purposes of monitoring the provision of services. A foster care case is generally based on the placement of an individual child, although casework for the child may include services to the child's family. A child protective services case is based on an entire family household if a family assessment model is used; otherwise a case is defined as a child.


	CLINICAL The study, assessment, and diagnosis of the client situation followed by direct treatment to help the client achieve prescribed goals.


	PRACTICE Established actions or ways of proceeding in the regular performance of organizational duties. Policies and procedures often guide practice.


	PERSONNEL The body of employees and/or volunteers that carries out the organization's tasks under the organization's administration and/or supervision. This definition does not include foster parents who are specifically referenced in relevant standards


	UTILIZATION REVIEW A process whereby an organization uses established criteria to evaluate the services and resources provided to consumers in terms of their necessity, appropriateness, and cost-effectiveness.


	MANAGEMENT See ADMINISTRATION


	DISCHARGE See CASE CLOSING


	CLIENT See service recipient.


	TRAINING Instruction so as to make fit, qualified, or proficient in a skill or body of knowledge.


	PLANNING The process of specifying objectives, evaluating the means for their achievement, and exercising deliberate decision making about appropriate courses of action.


	APPROPRIATENESS The degree to which a particular service, placement, treatment, intervention, or activity is: best suited to an individual's needs; not excessive, unduly intrusive, or restrictive; anticipated to be effective in achieving the desired and specified outcomes; and adequate or sufficient in quantity to address the problem.


	INTAKE The client's entry point for services at which eligibility is assessed against established criteria and a preliminary evaluation of the presenting problem occurs.


	SAMPLE A portion or representative percentage of a greater whole.


	CASE RECORD A written compilation that describes the client and the services delivered. Records can be in hard copy and/or electronic format. The case record can be used as a source of information for quality improvement or other evaluation activities, for research purposes, or to demonstrate accountability to funding bodies.