Mental Health Services: Utilization Review Plan

A mental health program must have a utilization review plan that is acceptable to the MassHealth agency and that meets the following conditions. (A) A utilization review committee will be formed, composed of the clinical director (or a designee), a psychiatrist, and one other professional staff member from each core discipline represented who meets all the qualifications for the discipline, as outlined in 130 CMR 410.475. (B) The utilization review committee will review a representative sample of cases at least in the following circumstances: (1) within 90 days after initial contact; (2) when a member has required more than 50 visits every 12 months and has not required hospitalization or extensive crisis intervention during that period; and (3) following termination. (C) The utilization review committee will verify for a representative sample of cases that (1) the diagnosis has been adequately documented; (2) the treatment plan is appropriate and specifies the methods and duration of the projected treatment program; (3) the treatment plan is being or has been carried out; (4) the treatment plan is being or has been modified as indicated by the member's changing status; (5) there is adequate follow-up when a member misses appointments or drops out of treatment; (6) there is progress toward achievement of short- and long-term goals; and (7) for members younger than 21 years old, the CANS has been completed at the initial behavioral health assessment and updated at least every 90 days thereafter as part of the treatment plan review. (D) No staff member will participate in the utilization review committee's deliberations about any member that staff member is treating directly. (E) The program will maintain minutes that are sufficiently detailed to show the decisions of each review and the basis on which any decisions are made so that the MassHealth agency may conduct such audits as it deems necessary. 4. Program Regulations (F) Based on the utilization review, the director of clinical services or a designee will determine whether continuation, modification, or termination of treatment is necessary and promptly communicate this decision to the primary therapist.