DOCCS is seeking proposals for a statewide utilization management program which will use standardized criteria for the review and determination of medical necessity of all secondary and tertiary care requested on behalf of incarcerated individuals within DOCCS’ custody. This is to include incarcerated individuals in work release programs. The contractor must: • Process referrals for specialty care services and communicate as needed with each of DOCCS’ health units and Central Office via DOCCS’ Clinic Scheduling System. • Provide a decision on the same business day for any “emergent” and/or “urgent” referrals as outlined below: o Approve: Contact the appropriate nurse scheduler. o Pend: Notify the requesting facility by phone. o Preliminarily Deny: Send a high priority email to the Regional Medical Director (RMD) or Regional Dental Director (RDD) for that facility. The RMD or RDD is responsible for making the final determination. • Render an electronic decision within one (1) business day for all “soon” referrals, three (3) business days for all “routine” referrals, and five (5) business days for all “assigned” referrals. If a referral cannot be approved with the information given, the referral can be pended back to the facility’s primary care provider for additional information, or if further information is not needed to support the request or would not be helpful, the referral is to be preliminarily denied to the RMD/RDD. • Verify ALL inpatient and outpatient medical and oral surgery claims for payment via DOCCS’ FHS1 Medical Claims Processing System by utilizing DOCCS’ FHS1 Clinic Scheduling System or DOCCS ClaimConnect Medical Bill Payment Software System and other available means to confirm health care delivery. Vendor will have access to all incarcerated individuals’ medical referrals, appointments, etc. via the DOCCS’ FHS1 system and DOCCS ClaimConnect Medical Bill Payment Software System to aid in this process
