Nevada Health Solutions Clinical Utilization Management Program

Introduction

The Nevada Health Solutions Utilization Management Program directs and monitors the use and quality of health care services provided to its patients. The program includes pre-services, concurrent, and retrospective review and evaluation of the utilization of services provided to patients.

It is designed to optimally manage healthcare resources to maximize the cost effectiveness and quality of the care provided to patients. It is structured to promote fair, safe and consistent utilization management decision-making. The program is under the clinical supervision of the Medical Director, a Nevada licensed physician; and the Senior Director of Medical Management, a Nevada licensed RN. Both provide support to develop and implement the program.

The program is updated as necessary, and is evaluated and approved annually by the Utilization Management Committee and the Quality Committee.

The following summary highlights some of the primary functions of the Utilization Management Program that serves to ensure patients’ easy access to the most appropriate and efficient quality care to promote improved health outcomes.

Purpose

The purpose of the Utilization Management Program is to provide a comprehensive, integrated process that ensures patients in all age groups from new born to geriatric receive timely, safe, and appropriate medical care in the most efficient and cost-efficient manner. The program provides a comprehensive process of review of inpatient and outpatient medical services for self-funded and commercial plans as contracted. This process assures the delivery of medically necessary, optimally achievable, quality patient care through appropriate utilization resources in a cost effective and timely manner.

The focus of the Program is to ensure efficiency and continuity by identifying, evaluating, monitoring, and correcting elements that affect the overall effectiveness of the utilization management process. The program’s activities are developed and implemented in compliance with state and federal regulations.

Moreover, in order to continually assess and improve the quality of care available to patients, the program interfaces with the Quality Committee to facilitate the achievement of its goals and objectives.

Description

To read the Utilization Management Program description, click here.

Guidelines

By clicking on “View Medical Policies” below, I acknowledge that I have read and understood the following:

Nevada Health Solutions (NHS) uses Clinical Utilization/Management Guidelines (U/M Guidelines) to determine the medical necessity of requested medical services. The U/M Guidelines include medical policies developed by NHS (Medical Policies) as well as the following MCG Care Guidelines®; Inpatient and Surgical Care Guidelines®; General Recovery Care Guidelines®; and Ambulatory Care Guidelines® (together, the MCG Care Guidelines®).

The Medical Policies are posted here for informational purposes only. The Medical Policies are written for a medical professional audience. Individuals should discuss any information they read in the Medical Policies with their treating health care professionals. The Medical Policies do not constitute, and should not be taken as, medical advice or medical care. NHS does not provide, and is not responsible for, any medical advice, diagnosis, or treatment.

Ultimately, benefit determinations are subject to all terms and conditions of the individual’s applicable health plan, including specific exclusions and limitations, as well as to applicable state and/or federal law. The U/M Guidelines, including the Medical Policies and MCG Care Guidelines®, do not constitute, and should not be taken as, plan authorization or an explanation of benefits. Because health plans vary in coverage, some plans may not provide coverage for certain services that are addressed in the U/M Guidelines.

The U/M Guidelines are subject to change at any time without notice. However, NHS will make reasonable efforts to keep the Medical Policies, as posted on this web site, updated. Health plan members should contact their local customer services representatives for specific coverage information. NHS does not allow the Medical Policies to be copied, printed or downloaded from this web site for any reason.

The licensed standard and customized MCG Care Guidelines® are the property of MCG Health, LLC, and are not posted on this web site. If you would like to request a paper copy of a specific section of the Medical Policy, MCG Care Guidelines®, or another section of the U/M Guidelines, you may contact Nevada Health Solutions.

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