Question

There are criteria provided by major sources to support clinical review/medical necessity.

Investigate the sources of clinical review criteria and guidelines and provide information on what they provide and how they can be helpful to the case management process and your client?

Answer 1

PURPOSES OF GUIDELINES: To describe appropriate care based on the best available scientific evidence and broad consensus; To reduce inappropriate variation in practice; To provide a more rational basis for referral; To provide a focus for continuing education; To promote efficient use of resources; To Act as focus for quality control, including audit; To highlight shortcomings of existing literature and suggest appropriate future research New Directions believes that high quality and appropriate behavioral health care services should follow the six aims for health care based on the Institute of Medicine. Services provided should be safe, timely, effective, efficient, equitable, and patient-centered. Additionally, we embrace the “Triple Aim” for health care: Improving the patient experience of care (including quality and satisfaction) Improving the health of populations Reducing the per capita cost of health care HOW CAN BE HELPFUL A. Consistent with: 1. The evaluation, diagnosis, prevention, treatment or alleviation of symptoms of an illness, disease or injury 2. Generally accepted standards of medical practice, as defined by credible scientific evidence published in peer-reviewed medical literature, which are generally recognized by the appropriate medical community, Physician Specialty Society recommendations and other relevant factors B. Clinically appropriate and designed to meet the individualized needs of the patient with regard to type, frequency, extent, site and duration of services C. Considered effective to improve symptoms associated with the patient’s illness, disease, injury or deficits in functioning D. Provided at the least restrictive and most clinically appropriate service or level of care to safely, effectively, and efficiently meet the needs of the patient E. Required for reasons other than the convenience of the patient, family/support system, physician or other health care provider F. Not a substitute for non-treatment services addressing environmental factors G. Not more costly than an alternative service or services, which are at least as likely to produce equivalent diagnostic or therapeutic results for the patient’s illness, disease or injury