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General Purpose The purpose of the Utilization Management program at PsychStar is to assure appropriate allocation of member resources by striving to provide high quality behavioral healthcare services in the less restrictive and most cost effective manner. Utilization management is organized and structured to plan, organize, direct, and manage behavioral healthcare in a cost-effective manner, while maintaining a high quality of care and contributing to the overall goals of the network. This is accomplished through the judicious use of resources to control inappropriate referrals, over-extended length of treatment, over-extended lengths of hospital stay and the over-utilization of tests and procedures.

Methods: Utilization Management reviews provide PsychStar with a mechanism to effectively plan and manage the member’s use of services, the use of net work resources and eliminate costly over and under utilization of network resources. There are four (4) types of clinical review performed by the Utilization Management Department. The clinical reviews are as follows:

Initial or Prospective Review

Concurrent Review

Continuation of Care

Retrospective Review

The information used to make the utilization management determinations come from various sources. Information sources many include but are not limited to medical records, telephonic reviews, interviews, referral reports and treatment plans. The practice guidelines are used for the determination of medical necessity, severity of illness, intensity of service, for inpatient and outpatient mental health and substance abuse, and the length of stay/service. The criteria sources are established.

Quality Improvement: The Utilization Management Department monitors and reviews appropriateness of service, medical necessity as well as statistics and satisfaction. Monitoring areas of specific interest are as follows: Member Satisfaction Survey and Provider Satisfaction Survey, Organizational Determinations and/or Reconsideration/Appeals and Medical Records Reviews

Goals for the utilization management program

Managed behavioral healthcare service to provide high quality of care in an efficient and cost-effective manner.
Coordinate interdisciplinary team members and community resources to provide a comprehensive system of service delivery.
Coordinate all member care support services with provider’s plan of care.
Initial discharge planning on admission to inpatient hospitalization, partial hospitalization programs, and outpatient programs.
Assure high quality of continuum of care by:

	- Identifying opportunities for improvement.
	- Developing quality improvement monitors.
	- Evaluating clinical records for documentation, interventions and
	patient outcomes.

Identify and evaluate utilization trends such as length of stays by facility unit and diagnosis specific criteria.
Develop a mechanism for evaluation of member outcomes for the member with complex post-discharge plans of care.