Ohio Utilization Review of Inpatient Psychiatric (URIP) Care Provided to Medicaid Recipients
The Ohio Utilization Review for Inpatient Psychiatric (URIP) Care Provided to Medicaid Recipients is a statewide program funded by the Ohio Department of Mental Health (ODMH) for Medicaid fee-for-service recipients. Health Care Excel (HCE) developed, revised, and has maintained the program since its inception in 1996, providing continuity in management resulting in positive relationships among ODMH, HCE, and the provider community.
The Ohio Department of Job and Family Services (ODJFS) is responsible for the implementation and administration of the Ohio Medicaid Program. ODJFS delegated responsibility to the Ohio Department of Mental Health (ODMH) for the Utilization Review of Psychiatric Hospital Inpatient Services (URIP) provided to Medicaid recipients not enrolled in Medicaid Health Maintenance Organizations (HMOs). Health Care Excel, Inc. (HCE) is the servicer of the Ohio URIP program.
Pursuant to Federal and State Medicaid regulations, HCE performs pre-admission certification, retrospective reviews, and post-payment reviews of inpatient psychiatric admissions to monitor the following aspects of care.
- Clinical appropriateness of inpatient psychiatric care
- Quality of discharge planning and continuity of care
- Adequacy with which facilities providing psychiatric care meet applicable provisions of State and Federal guidelines governing this care
Pre-admission Certification Process
Pre-admission certification review is a process whereby ODMH assures that Ohio Medicaid recipients receive psychiatric care in the most appropriate and cost-effective setting. The pre-admission certification review process must be initiated by the provider and admitting hospital within one business day after admission. All pre-admission certification reviews must be completed for each psychiatric admission.
Retrospective Review Process
Due to the implementation of MITS within the Medicaid billing process, providers are no longer able to bypass the precertification process utilizing the “AN” code for Medicaid recipients gaining benefits retroactively on the billing claim. As a result, retrospective reviews were processed beginning in November 2011. Providers must submit a request for a retrospective review via the Ohio State Medicaid Information Technology System (MITS), providing documentation that Medicaid eligibility was verified on the date of admission. If documentation is provided showing the patient did not have Medicaid benefits on the date of admission, yet received benefits retroactively, the request is approved.
Post-payment Review Process
The post-payment review process is conducted to satisfy State and Federal utilization control requirements based on application of criteria to specific categories of admission. The specific categories of admission to be reviewed include children’s admissions (under nine years of age), readmission, outlier payments, short lengths of stay (less than three days), transfers, hospital denial letters, and compliance with the pre-certification program.
Access to Ohio URIP QUESt is available through the following link: https://ohiourip.hce.org/Login.aspx
Ohio Utilization Management for Specified Community Mental Health Medicaid Services (Ohio CMH)
Health Care Excel, under the direction of the Ohio Department of Mental Health, performs prior authorizations for Partial Hospitalization (PH) and Community Psychiatric Supportive Treatment (CPST) to evaluate the medical necessity of treatment for both kids and adults who need services beyond the benefit limit.
Ohio-licensed clinical reviewers evaluate prior authorization requests using an established and approved set of medical necessity criteria. When clinical information supports the need for continued services, an approval is rendered. If the clinical information provided does not support the need for additional treatment, the case is deferred to an Ohio-based, board certified psychiatrist for review.
Before a recipient reaches the service limits for either PH or CPST services, a Prior Authorization (PA) for continued services must be obtained.
Ohio CMH Resources
Health Care Excel and Ohio Department of Mental Health Training Power Point Presentations October and November 2011
- Introduction to the Prior Authorization Process (Presented by Health Care Excel staff)
- Budget Overview and Office of Health Integration 2013 Work Plan (Presented by Terry R. Jones, LISW-S, Manager of Program compliance)
- Community Mental Health Medicaid Benefits (Presented by Kathy Cluggish, Macsis Support Desk Supervisor)
- Provider Web Portal (Presented by Kathy Cluggish, Macsis Support Desk Supervisor)
- Ohio CMH On-Line User Registration
- Ohio CMH Agency Contact Registration Form
- Ohio CMH Prior Authorization Form
- Ohio CMH QUESt
Ohio CMH Provider Handbook
- Overview of Prior Authorization Process
- Medical Necessity Criteria
- Exemptions to Prior Authorization
- Units of Service and Retro Authorization Requests
- Prior Authorization Process
- Appeal Process
- Prior Authorization Form
- Submitting prior Authorization Requests
- Contacting Health Care Excel
- Contacting State Agencies and Resources
- Recognized Holidays
- Glossary of Terms