Organization of the department

 Authority:   PsychStar is contracted to provide mental health and substance abuse services. The ultimate responsibility for the utilization management of behavioral health services provided rests with the Board of Directors of PsychStar. The Board of Directors of PsychStar will provide oversight in the manner in which all clinical disciplines, services, and providers participate in the Utilization Management process.

The responsibility for the execution of the Utilization Program and Plan is assumed by the UM/QI Committee and are carried out by the UM Department. The procedures, authority and accountability outlined in the program are designed to satisfy the standards of the Office of Licensure and Certification, and third party payer requirements.

Delegated functions: Psychiatric and substance abuse triage, referrals, case management, and the assignment of care are all delegated functions of PsychStar from the Health Plan. The delegated functions are assigned as per contract with the Health Plan and are carried out by the Utilization Management Department. Evaluations are performed on each function on an annual basis to ensure that criteria and standards are appropriately and uniformly applied to all PsychStar cases. The Health Plan will perform medical record reviews, and credentialing to all provider networks. PsychStar will communicate network performance evaluations to the appropriate organizations.

PsychStar offers the following services to enrolled members: psychiatric evaluations, outpatient psychotherapy, child/adolescent, geriatric and forensic psychiatry, medication management, and acute inpatient care and crises stabilization.

Department organization: The Medical Director is responsible for the development of the Utilization management program and the UM/QI Plan. The responsibility for the implementation the program and the UM/QI Plan will rest with the Utilization Management/Quality Improvement Committee. The Medical Director provides oversight and the direction to the integration of all utilization management activities.

Utilization Management is an integral part of the management of PsychStar. All providers are encouraged to become involved in the utilization program to fulfill their duties as completely as possible. Requirements to participate in UM activities are incorporated in all provider contracts.

The Medical Director is responsible for the planning, implementing, controlling, and evaluating healthcare delivery programs and operations. The Medical Director heads both the Utilization Management Department and the Medical Management. The Medical Director also may functions as one of the primary Physician Reviews. The Medical Director documents through reports, which are stored in UM case files and in the MIS. The Medical Director reports to the UM/QI Committee, and to the Board of Directors.

The Physician Reviewer (PR) is defined as a licensed psychiatrist who provides consultation to non-physician reviewers on the appropriateness of quality, and/or medical necessity of a member’s referral, treatment, admission to or continued stay in the hospital. The Physician Reviewer has been appointed from, and acts for the UM/QI Committee. The (PR) documents on consultation forms and reports to the Medical Director.

The Physician Advisor Consultant (PAC) is defined as a Physician Reviewer who provides a second opinion on cases requiring physician consultation during concurrent review process.

The Utilization Management Care Coordinator (CC) reviews appropriateness of referrals, admissions, and continued treatment/stay using norms and criteria approved by the UM/QI Committee. The Utilization Management Care Coordinator involves the Medical Director in cases that include but are not limited to potential denials, deviations from practice standards, and/or issues with providers.

The Case Manager (CM) is responsible for determining eligibility, reviews, data collection, and acting as a liaison with plan members and providers for PsychStar. The Case Manager reports activities and issues to the UM Coordinator.The Customer Service Representative (CS) is defined as a PsychStar staff member who is responsible for the incoming calls, demographics data collection, and acts as liaison with the general public and plan members. The CS Representative documents all requests for service, inquires for information about PsychStar and all complaints, on call log form and forwards all information, to the risk management customer services department.