Gila River Health Care Corporation
Gila River Health Care Corporation
PROVIDER MANUAL
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Arizona Department of Health Services

Division of Behavioral Health Services
PROVIDER MANUAL
Gila River Regional Behavioral Health Authority Edition

8.5.1 Introduction
Medical Care Evaluation (MCE) Studies are an established method to promote the most effective and efficient use of available services consistent with recipient needs and professionally recognized standards of care for persons receiving treatment in an Arizona Department of Health Services/Division of Behavioral Health/Office of Behavioral Health Licensing licensed Level I facility. ADHS/DBHS has established guidelines for the development and reporting of MCE studies and ensures that each Tribal/Regional Behavioral Health Authority (T/RBHA) has a review process in place to confirm that required MCE Studies are undertaken, completed, analyzed, and utilized to improve behavioral health recipient care. This section outlines the provider’s role in this process.

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8.5.2 References

8.5.3 Scope
To Whom Does this Apply?

  • All OBHL licensed Level I subcontracted providers.

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8.5.4 Did you know...?

  • T/RBHAs must ensure that all OBHL licensed Level I subcontracted providers (See Participating providers) adhere to the MCE study requirements.

ADHS/DBHS will ensure the systematic application of MCE study topics and methodologies across T/RBHAs via review of statewide utilization data trends. T/RBHA proposed MCE study proposals, study methodologies and supporting data will be reviewed via the ADHS/DBHS MM/UM Committee. Final approval of ADHS/DBHS systemic MCE studies will occur at the ADHS/DBHS MM/UM Committee.

8.5.5 Objectives
To establish a method to promote the most effective and efficient use of available facilities and services consistent with recipient needs and professionally recognized standards of health care.

8.5.6 Procedures


8.5.6-A. Participating providers
Who participates?
The following provider types must conduct MCE studies:

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8.5.6-B. Participating provider responsibilities and requirements
Request for Registration
By May 31st of each year, each participating subcontracted Level I provider as described in Section 8.5.6-A must submit PM Form 8.5.1, MCE Study Request for Registration and Evaluation Methodology, to the T/RBHA for the upcoming state fiscal year.

Timeframe
The standard study period for MCE studies starts on July 1st of each year through June 30th of the succeeding year. Deviations from this study period and all longitudinal studies must be pre-approved by the ADHS/DBHS Bureau of Quality Management Operations prior to initiation. Any request for exemption shall be made in writing and received by ADHS/DBHS within two (2) weeks from the date the T/RBHA received the  PM Form 8.5.1, MCE Study Request for Registration and Evaluation Methodology.

Methodology
For T/RBHA subcontracted providers that provide Title XIX certified inpatient hospital, mental hospital, residential treatment center or sub-acute services, the subcontracted provider’s Quality Management or Utilization Review Committee proposes the methods to be used in selecting and conducting medical care evaluation studies in the subcontracted provider facility. The conduction of the MCE study is the responsibility of the facility that provides the service. PM Form 8.5.1, MCE Study Request for Registration and Evaluation Methodology, must be used to describe the proposed methodology.

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Each MCE Study must:

  • Identify and analyze medical or administrative factors related to the subcontracted provider facility’s behavioral health recipient care;
  • Include analysis of at least the following:
    • Admissions;
    • Length of stay;
    • Ancillary services provided including drugs and biologicals; and
    • Professional services performed;
  • Include recommendations for improvements beneficial to behavioral health recipients, staff, the facility and the community; and
  • Use data obtained from one or more of the following sources: dependent on the scope of the MCE study: medical records of other appropriate subcontracted provider facility data; profiles and other comparative data; and/or secondary data sources, such as external organizations that compile utilization statistics.

Documenting, Analyzing and Reporting Study Findings

  • Each Level I subcontracted provider facility will document the results of each study as well as how the results have been used to make changes to improve the quality of care to recipients and promote more effective and efficient use of facilities and services.
  • Each Level I subcontracted provider facility will analyze its findings for each study and take action as needed to correct or investigate any deficiencies or problems in the review process for admissions or continued stay cases.
  • Each Level I subcontracted provider facility shall recommend, as appropriate, more effective and efficient facility care procedures based on study findings.

Each Level I subcontracted provider must submit a final MCE study report to the home T/RBHA by July 31st of each year. This report will include an in-depth analysis and narrative of how the subcontracted provider facility plans to use the information to improve care. To provide the final study report, please submit PM Form 8.5.2 Medical Care Evaluation – Provider and T/RBHA Review of Final Results to the Gila River RBHA QI Manager. If the MCE study results and analysis are not approved by the home T/RBHA, the home T/RBHA must conduct follow up activities with the provider to finalize the study. Please contact Gila River BHS QI Manager at 602-528-7100 for further information regarding the submission of MCE studies.

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8.5-Medical Care Evaluation Studies
Last Revised: 08/30/2012
Effective: 10/1/2012

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