Section 132.95  Utilization Review

The provider shall have a written utilization review (UR) plan and ongoing assessment of the medical necessity of Medicaid community mental health services, including the intensity/level of services and continued need for each service for the client.  The written UR plan shall address:

a)         A review of medical necessity or that services are medically necessary, as determined by: 

1)         The definition of medical necessity in this Part;

2)         The type, severity and chronicity of the client's symptoms;

3)         The severity of impairment in the client's role functioning;

4)         The risks that a client's symptoms or level of role functioning pose to the safety of the client or to others with whom the client interacts;

5)         The expected short-term and long-term outcome of each service needed by the client; and

6)         Progress made in response to treatment, if the client is currently receiving treatment;

b)         The methods and procedures for performing and recording individual case reviews by persons not involved in providing services to the clients whose records are reviewed;

c)         The authority and functions of the individual case review designated unit, which may be:

1)         A representative committee, chaired by a QMHP, and including QMHPs, MHPs, and RSAs; or

2)         A QMHP;

d)         Procedures describing the method for selecting cases for quarterly case review and the procedures for reviewing 10 percent of the clients served under this Part annually;

e)         Procedures to ensure that the review includes and summarizes the client's progress over the previous 90 days;

f)         Procedures to ensure that the review includes and summarizes the client's involvement in service planning and provision over the previous 90 days;

g)         Policies and procedures for documenting and reporting individual case reviews findings, determinations and recommendations to the supervising QMHP and, if applicable, the billing department;

h)         Procedures for appeal by clients and staff affected by the UR decisions with which they disagree;

i)          Provisions for ensuring confidentiality of individual case reviews, determinations, results and/or recommendations in accordance with the Confidentiality Act and HIPAA; and

j)          Procedures for following up on case review recommendations.

(Source:  Amended at 36 Ill. Reg. 18582, effective December 13, 2012)