Medicaid Physician Review and Consulting Services

The Vendor is required to provide medical oversight, prior authorization case review and medical necessity determinations in a Medicaid Managed Care environment.
- Provide consultative services on these activities, on an as needed basis, not to exceed sixteen (16) hours per week, according to a mutually agreeable schedule as established by the contractor, the state clinical operations unit director and the state’s chief medical officer.
- Request and/or seek any additional clinical information necessary from the treating and/or referring Provider in order to complete the reviews in a timely manner.
- When the Chief Medical Officer is unavailable, Contractor shall review beneficiary appeals regarding requests for medical services that have previously been denied, and other duties as may be assigned during any absence of the Chief Medical Officer.
- When evidence-based national criteria for medical necessity are unavailable, Contractor shall research, recommend and/or review any clinical criteria that have been developed by the State. If necessary and as approved by the State, Contractor shall seek out subject matter experts for consultation.