Utilization Review Plan

The community behavioral health center must have a utilization review plan that meets the following conditions. (A) A utilization review committee will be formed, composed of the clinical director or the clinical director’s designee and two other professional staff members who meet all the qualifications for their discipline, as outlined in 130 CMR 448.415. The composition of the utilization review committee will be reported to MassHealth as set forth in 130 CMR 448.406. (B) The utilization review committee will review each member’s case in accordance with the Department of Public Health regulations at 105 CMR 140.540 and following the member’s discharge from services at the center. (C) The utilization review committee will verify for each case that (1) the diagnosis is, or has been, adequately documented; (2) the treatment plan is, or was, 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, or was, adequate follow-up when a member misses appointments or drops out of treatment; (6) there is, or was, progress toward achievement of short and long-term goals; and (7) for members younger than 21 years of age, the CANS has been completed at the initial behavioral health assessment and updated at least every 90 days thereafter. (D) No staff member can participate in the utilization review committee’s deliberations about any member the staff member is treating, or has treated, directly. (E) The utilization review committee will maintain minutes that are sufficiently detailed to show the decisions of each review, and the basis on which any decisions are made. The MassHealth agency may conduct such audits of these minutes as it deems necessary. (F) Based on the utilization review, the clinical director, or the clinical director’s designee, will determine whether continuation, modification, or termination of treatment is necessary and promptly communicate this decision to the primary therapist.