Standards for private organizations

2020 Edition

Network Administration (NET) 7: Utilization Management

The network management entity 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.
2020 Edition

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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.
1
The organization's practices fully meet the standard, as indicated by full implementation of the practices outlined in the NET 7 Practice standards.
2
Practices are basically sound but there is room for improvement, as noted in the ratings for the NET 7 Practice standards.
3
Practice requires significant improvement, as noted in the ratings for the NET 7 Practice standards.
4
Implementation of the standard is minimal or there is no evidence of implementation at all, as noted in the ratings for the NET 7 Practice standards.
Self-Study EvidenceOn-Site EvidenceOn-Site Activities
  • A description of the scope of utilization management activities (For example, does utilization management include authorization that is external to the provider? Is it limited to establishing criteria, reporting utilization data, and retrospective reviews?)
  • Utilization management procedures, including:
    1. Criteria for placement decisions
    2. A process for approving the criteria and making the criteria available to those applying the criteria
    3. Service authorization and
    4. Appeals, and notifications of appeals when requests are denied
    5. Data collection and review
    6. The review of contractor case records, including sampling methodology
  • Most recent quarterly review of authorization and placement decisions
  • Most recent annual report from the contractor case record review process
  • Job descriptions
  • Utilization management reports, including data reviews
  • Records of authorization decisions, including the application of the criteria to the decision
  • Records of utilization management reviews at provider locations
  • Evidence of the source of utilization management criteria

 

  • Interviews may include:
    1. Care managers
    2. Clinical directors at provider organizations
    3. Independent practitioners
    4. Direct service providers
  • Review personnel files of utilization management staff

 


 

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.

Interpretation

Network management entities manage utilization in several ways; however, in all cases, they need criteria that help guide service delivery decisions.
Examples: Sources for utilization criteria commonly include expert panels or bodies, such as the American Society of Addiction Medicine (ASAM), or the purchaser. A network management entity may also rely on appropriately qualified, direct-service providers to develop its own criteria based on nationally recognized practice guidelines.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement.
3
Practice requires significant improvement.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

NET 7.02

Utilization management criteria are available upon request to network service providers, and the network management entity identifies the source or sources of the criteria.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement.
3
Practice requires significant improvement.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

NET 7.03

Utilization management personnel are qualified as follows:
  1. personnel conducting utilization reviews have appropriate experience and training;
  2. supervisors of service authorization personnel have appropriate experience and possess relevant credentials;
  3. medical necessity decisions are made by licensed and qualified clinicians; and
  4. appeals are reviewed by persons who are licensed or credentialed to provide the service under review.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement.
3
Practice requires significant improvement.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

NET 7.04

Network management entities 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 management entity does not provide authorization for services.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement.
3
Practice requires significant improvement.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

NET 7.05

Utilization management includes, as appropriate to the services being provided, a regular review of data related to:
  1. appropriateness of admissions and authorization decisions, if authorizations are part of network services;
  2. intake and referral processes;
  3. service planning and service delivery milestones; and
  4. 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.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement.
3
Practice requires significant improvement.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

NET 7.06

The network management entity conducts:
  1. 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
  2. at least annually, a review of ten percent of contractor case records.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement.
3
Practice requires significant improvement.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

NET 7.07

Network management entities that conduct preauthorization and reauthorization for services:
  1. respond to requests for authorization, initial screening, or reauthorization according to standards for timeliness that are in proportion to the urgency of the request;
  2. provide a 24-hour response line when responsible for authorization of crisis, emergency, or urgent care; and
  3. record the reason for placement decisions and relate this decision to criteria.
NA The network management entity does not provide pre- or continuing authorization for services.
Note: When network management entities provide these initial or continuing authorizations, these more intensive utilization management activities are usually provided as a core network service. 
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement.
3
Practice requires significant improvement.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

NET 7.08

If authorization for services is denied, the network management entity:
  1. informs the person or service provider requesting the authorization of the reason for the denial;
  2. relates the reason for the denial to the criteria used for making authorization decisions; and
  3. informs the person or service provider of the right to appeal the denial of authorization and the timeframes for the appeal.

Interpretation

For the purposes of 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.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement.
3
Practice requires significant improvement.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.

 

NET 7.09

Timeframes for appeals of denials of service authorizations:
  1. ensure that appeals are reviewed and the results communicated in time for the service recipient to enter or continue services without interruption; and
  2. vary according to the urgency of the issue.
1
The organization's practices reflect full implementation of the standard.
2
Practices are basically sound but there is room for improvement.
3
Practice requires significant improvement.
4
Implementation of the standard is minimal or there is no evidence of implementation at all.