Utilization Management

NOTE: Failure to request and receive a prior authorization from Children's Mercy Pediatric Care Network (PCN) may result in denial of payment. All claims are subject to verification of eligibility and benefits. Authorization does not guarantee payment. See the Authorization Quick Guide for Missouri Pediatric Care Network Members.

Inpatient Admissions: Scheduled and non-emergent inpatient admissions require notification and clinical information at least two (2) business days prior to the services being rendered. Emergent services require notification to the PCN within ten (10) business days after admission. The participating providers are responsible for communication of clinical information to the PCN. Newborns remaining in the hospital after the mother is discharged require an authorization for continued inpatient services.

Medical Review Process: Medical review is conducted to confirm the medical necessity of treatments or services rendered, as well as the appropriateness of the care setting. Medical review requires evaluation of specific clinical information that is obtained from onsite reviewers, over the telephone or from written communication. PCN Care Navigators compile all pertinent clinical information gathered from the treating practitioners/staff, review the information using medical necessity decision criteria and consider individual patient needs, as well as the local healthcare delivery system. Once the review is complete, the Care Navigator confirms medical necessity, the appropriateness of the care setting, and authorizes the requested service. When medical necessity and/or appropriateness of the care setting cannot be confirmed, the case is referred to a Board Certified physician for review. Any denial decisions are done by a Board Certified physician.

If you would like a copy of the criteria, please click on the associated links below or contact the PCN Prior Authorization Department at 1-877-347-9367 for MO PCN Members and 1-833-802-6427 for KS PCN Members or fax your request to 1-888-670-7260. A written copy of the criteria will be mailed or faxed within three (3) business days of your request. Cosmetic Procedures • Private Duty Services

Contacting UM: Medical review staff members are available for questions related to prior authorization and coverage: Monday – Friday, 8:00am – 5:00pm. They can be reached by toll free phone at 1-877-347-9367 for MO PCN Members and 1-833-802-6427 for KS PCN Members or toll free fax at 1-888-670-7260. The same toll free phone number and toll free fax number are available 24/7 for communication of utilization management issues. Information left after normal business hours should include: caller's name and contact number, member name, member ID number, and the reason you are calling. The request will be responded to the next business day. PCN UM Office Hours

Statement on Incentives: The Children's Mercy Pediatric Care Network makes all review decisions based only on the appropriateness of care and service, the existence of coverage for the member, and his or her unique health needs. PCN does not specifically reward providers or other individuals for issuing denials of coverage. Financial incentives for UM decision making do not encourage decisions that result in underutilization.

If you would like to discuss a decision with a PCN Medical Director, you may call the Prior Authorization Department at 1-877-347-9367 for MO PCN Members and 1-833-802-6427 for KS PCN Members and ask to speak with the Medical Director.

Appeals Information:

• Appeals for UnitedHealthcare Community Plan of Kansas Members
• Appeals for UnitedHealthcare Community Plan of Missouri Members
• Appeals for Healthy Blue of Kansas Members
• Appeals for Healthy Blue of Missouri Members

Care Integration Programs

The Pediatric Care Network (PCN) offers a comprehensive care integration program, consisting of complex case management (CM), disease management (DM), care coordination and population health to eligible members. The care integration program focuses on preventive health and enhancing and coordinating a member’s care across an episode or continuum of care; negotiating, procuring and coordinating services and resources needed by members and families with complex issues; facilitating care transitions across care settings; ensuring and facilitating the achievement of quality, clinical and cost outcomes; intervening at key points for individual members; addressing and resolving patterns of issues that have negative quality or cost impact and creating opportunities and systems to enhance outcomes. Through data analysis and identification of high cost or high risk trends, PCN continually assesses the characteristics and needs of the population and sub-populations being managed to identify opportunities to enhance and/or modify its care integration program. This includes children with special needs, disabilities, and other complex health issues. Disease management interventions focus on two chronic conditions that are relevant to the pediatric population; asthma and diabetes. PCN assesses all program interventions and resources to determine if changes are needed to better meet the needs of the population.

The goal of the care integration program is to help members sustain or regain optimal health in the right setting and in a cost effective manner. This is achieved through the well-coordinated efforts between the program staff and patient centered medical home practices. Including the primary care providers (PCP) in this integration assures continuity of care and alignment for improving health outcomes. The Care Integration staff work closely with the PCPs to assess the population’s needs, determine available benefits and resources, and develop and implement specific interventions to meet the population needs.

Circumstances that warrant referral to the case management team include but are not limited to:

• Presence of progressive, chronic, or life-threatening illness
• Need for inpatient or outpatient rehabilitation
• Terminal illness
• High risk pregnancies
• Acute/traumatic injury, or an acute exacerbation of a chronic illness
• Complex social factors
• Children with Special Health Care Needs
• Multiple hospitalizations or emergency room visits
• Elevated lead levels

To refer a patient for PCN's case management services, call Care Integration at 1-877-347-9367 for Missouri members and 1-833-802-6427 for Kansas members or use this referral form.

Case Management

Disease Management

Children's Mercy Pediatric Care Network (PCN) offers Disease Management programs for on appropriate diagnosis, treatment, and management utilizing the Patient Centered Medical Home (PCMH) model and PCN medical home team. The PCN medical home team includes care navigators and population health management network representatives. PCN's Disease Management programs are based on nationally recognized evidenced-based guidelines that can be accessed on the PCN website: www.cmics.org/pcn

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