MHS Adopting New Utilization Management (UM) Review Guidelines for behavioral health services

Date: 05/31/19

Effective July 1, 2019, Managed Health Services (MHS) will be adopting new Utilization Management (UM) Review Guidelines for behavioral health services and will no longer be using the previous InterQual developed guidelines.  MHS has adopted nationally recognized utilization review guidelines developed by MCG (formally known as Milliman Care Guidelines) and Indiana Health Coverage Program (IHCP) guidelines to assist in determining the appropriateness of medical and behavioral health services.

MCG and IHCP guidelines address medical, behavioral and surgical admissions, outpatient procedures including outpatient behavioral health and ancillary services. Guidelines are established, periodically evaluated and updated with appropriate involvement from physician members of the MHS Clinical and Service Quality Improvement Committee (CASQIC). MCG and IHCP care guidelines are utilized as a screening guide and are not intended to be a substitute for practitioner judgment. Review decisions are made in accordance with currently accepted medical, behavioral or healthcare practices, taking into account special circumstances of each case, which may require deviation from the normal screening guidelines. Guidelines are used by UM clinicians to determine medical necessity and approval of authorization request. If criteria is not met for approval, the UM nurse will refer the request and associated medical record information to an MHS Medical Director and/or Pharmacist. Medical Directors and/or Pharmacists are responsible for all medical necessity denial decisions.

Behavioral Health Practitioners who disagree with a determination based on medical necessity may request a medical necessity appeal.  All member or provider appeals of an MHS decision as to medical necessity must include a statement from the provider supporting the appeal and the need for the service. Each medical necessity appeal will be reviewed by an MHS Medical Director or Pharmacist. The reviewer may reverse the original decision and grant the appeal in whole or in part, or will uphold the original denial.

The appeal must be received by MHS within 60 calendar days of the date listed on the denial determination letter. The monitoring of the appeal timeline will begin the day MHS receives and receipt-stamps the appeal. Medical necessity behavioral health appeals should be mailed or faxed to:

MHS Behavioral Health

ATTN: Appeals Coordinator

12515 Research Blvd, Suite 400

Austin, TX 78701

FAX: 1-866-714-7991

For additional information and resources, including the MHS Provider Manual, please visit our website at mhsindiana.com/providers/resources. Thank you for being our partner in care.