About Utilization Management

Utilization Management Staff

Cardinal Innovations Healthcare's Utilization Management (UM) Unit is responsible for keeping track of the type, amount and how often services are used. UM is staffed by experienced clinicians who make authorization decisions to ensure members get the right care, in the right amount and at the right time.

This work is accomplished through the uniform application of Cardinal Innovations Healthcare's Practice Guidelines, North Carolina Division of Medical Assistance’s Clinical Coverage Policies, and community standards.

Each member's clinical needs are reviewed to determine the Medical Necessity for the services requested. The medical necessity criterion is based on the North Carolina Division of Mental Health, Developmental Disabilities and Substance Abuse Services’ service definitions1.

Medically necessary treatments are designed to:

  • Be provided in accordance with a Person Centered Plan
  • Conform to any Advance Medical Directives the individual has prepared
  • Respond to the unique needs of linguistic and cultural minorities and be furnished in a culturally relevant manner
  • Incorporate Evidenced Best Practices* and Emerging Best Practices* of care and services with the goal of improving positive outcomes in the community and the individual's quality of life and progress toward well-being
  • Prevent the need for involuntary treatment or institutionalization

Utilization Review
Utilization Review is a part of UM. The primary function is to monitor the utilization of services and review utilization data to evaluate and ensure that services are being provided appropriately within established benchmarks/clinical guidelines, and penetration goals are maintained. This will be accomplished using both Routine Utilization Reviews and Focused Utilization Reviews.

  • Routine Review
    • Sampling of identified services across Network Providers
  • Focused Utilization Review
    • Specific clinical concerns identified during data-based monitoring activities or findings generated from routine reviews

Utilization Management Staff
All utilization management decisions are made by qualified professionals under the supervision of appropriately licensed behavioral healthcare professionals.

  • All mental health and substance abuse Care Managers are required to meet full licensure in the area of practice.
  • All developmental disabilities Care Managers are required to meet the Qualified Professional status per the State of North Carolina.
  • All staff providing denials of service is required to be doctorate level licensed clinical psychologist or a psychiatrist or a physician.

1MHDDSAS Service Definitions:
http://www.ncdhhs.gov/mhddsas/statspublications/Manuals/index.htm
B3 Service Definitions >
1915 ( c ) Cardinal Innovations Waiver Service Definitions >

*Best Practices: recommended practices, including Evidenced Based Practices that consist of those clinical and administrative practices that have been proved to consistently produce specific, intended results, as well as, Emerging Practices for which there is a preliminary evidence of effectiveness of treatment.