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Utilization Management

UBA’s Utilization Management Program is designed to ensure the delivery of high quality, appropriate, and cost-efficient behavioral health care. It is the goal of the utilization management program to make sure that equal, consistent, and effective care is provided to all patients accessing behavioral care services across the network.

UBA’s Utilization Management Criteria sets reflect a “best practice” approach to patient care. The criteria used by the UBA’s clinical Utilization Review staff to determine medical necessity and clinical appropriateness have been developed and approved using evidenced-based standard protocols and guidelines e.g., MCAP Behavioral Health criteria, ASAM American Society of Addiction Medicine criteria, the Diagnostic and Statistical Manual for Mental Disorders (DSM-IV), The American Psychiatric Association, American Psychological Association, American Academy of Child and Adolescent Psychiatry, The National Institute for Mental Health, Medicare Guidelines, National Institutes of Alcohol Abuse and Alcoholism, The National Institute of Drug Abuse. The National Committee on Quality Assurance (NCQA) also guides UBA’s behavioral care services. The Utilization Management Program is updated, reviewed and approved annually by the UBA Executive Board and made available upon request. The criteria are updated as needed to maintain clinical relevance and management significance.

UBA's Utilization Management Services are designed to review utilization with a particular focus on detecting under- and over-utilization of services through a variety of oversight mechanisms. When a health plan requires that certain services be preauthorized, UBA conducts a prospective review to determine member eligibility, benefit coverage and medical necessity, and appropriateness of selected services. All inpatient admissions require notification are handled by UBA quickly and efficiently. UBA's staff obtains clinical information and conducts a review of the appropriateness of the admission. After admission, UBA conducts a continued stay review to assess the need for ongoing inpatient treatment in a hospital. UBA also conducts re-admission reviews to evaluate the quality of follow-up care and focus on discharge planning and ongoing case management needs. When UBA has not been prospectively alerted to an inpatient stay and a patient has been discharged, UBA’s Medical director will conduct retrospective review of the inpatient admission when the medical record documentation of this admission is received. A criteria-based review will be conducted to make a medical necessity decision about the level of care requested.

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