Since 2001, UMass Medical School has been responsible for clinical standards, case review, and utilization management for the Massachusetts Medicaid program, MassHealth. UMass Medical School, through the Center for Health Policy and Research, works with MassHealth to set treatment standards and review requests for certain services and procedures, ensuring they are medically necessary, appropriate, cost-effective — and in compliance with state and federal Medicaid regulations.
The prior authorization program covers 10 different classes of services, ranging from audiology to vision care, as well as coordination of care for medically complex cases. Service and care requests are reviewed by equivalent practitioners. The utilization management program provides similar review, but it focuses on acute care and chronic disease management programs instead. Prior authorization and utilization management for the pharmacy program are managed separately. Additionally, the Center for Health Policy and Research is responsible for developing the clinical standards and guidelines for services that require prior authorization.
UMass Medical School’s Center for Health Policy and Research, in conjunction with the state, reviews more than 10,000 service and care requests each month. This analysis and cross-check helps MassHealth save more than $36 million annually.