IV. Utilization Review

Substance Abuse and Mental Health Menu

An enrollee’s continued eligibility for the DSAMH LTC system will be monitored by the EEU. The EEU will analyze utilization patterns on an individual and aggregate basis for all enrollees and will identify enrollees whose utilization appear low given the individual's identified clinical needs at enrollment. When the EEU has identified under-utilizing consumers, it will ask the provider to submit a Consumer Status Review so that the EEU can work with the provider to analyze reasons for low service utilization; evaluate the provider’s response to the consumer’s use of service; and determine additional outreach activities which may be required.

The EEU will conduct sample chart reviews to review enrollees' clinical status, treatment, rehabilitation and support service needs and receipt of such services. All service utilization and provision will be assessed in terms of progressing toward recovery goals. The EEU will also review the “Days Lapse Report” to monitor consumers’ active service connection.

The EEU will notify the Primary Service Provider when it identifies consumers who have either not engaged in treatment or who appear to be withdrawing from treatment. When the EEU identifies an enrollee as potentially able to be disenrolled from the LTC system, it will conduct a clinical review with the Primary Service Provider to assess the individual's self-care potential and recovery status.

IV. Utilization Review

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