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Utilization Management (UM)

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The Utilization Management team consists of highly skilled master level - licensed clinicians who:

  • Provide leadership and management of the clinical program activities by facilitating ongoing program and policy development, policy application, and maintenance of critical relationships with system stakeholders, managed care organization and contracted providers.
  • Direct activities related to the provision of supports and services for individuals in Detroit & Wayne County with a Serious Mental Illness (SMI), Serious Emotional Disturbance (SED), Intellectual – Developmental Disability (I-DD) and Substance Use Disorders (SUD) as well as children eligible for the Autism Spectrum Disorder (ASD) Benefit Waiver as well as the Habilitation Service Waiver (HSW) and the Children’s Waiver Program (CWP). 
  • Developed and revise the DWIHN’s UM Guidelines and Benefit Grid to assist with the coordination of benefits and care.
  • Manage of all DWIHN utilization review clinical activities and services including fiscal, staffing, consulting and planning.
  • Assists in implementation and coordination of quality improvement activities and initiatives.
  • Provides oversight of the review process for clinical services requests that are consistent with the DWIHN Medical Necessity Criteria and/or other appropriate clinical criteria applicable to the clinical needs of consumers.

The purpose of the Utilization Management Unit is to facilitate the provision of quality, efficient behavioral health care services to consumers and providers through monitoring, evaluating and directing processes and behaviors, which impact the delivery of services. The overall goal of utilization management is to provide oversight and monitor treatment patterns of the delivery systems to ensure maximum efficiency.

Staff performing UM functions are not given financial incentives and are not otherwise rewarded to make UM decisions to reduce the provision of care which is deemed medically necessary or to encourage decisions that result in underutilization of care or services. Instead, DWIHN, Access Center, and COPE UM staff must review the initial and continued medical necessity on an individualized basis. If it is determined that the medical necessity criteria for a specific service is not met, all efforts will be made to link the individual to the services they need.

The UM Team maintains policies and processes that provide documentation of the framework and authority under which the UM Program operates. Reviewed and updated at least annually, the policies and processes support:

  • easy and early access to appropriate treatment
  • working collaboratively with participating providers in promoting delivery of quality care according to accepted best-practice standards and UM guidelines;
  • addressing the needs of special populations, such as children and the elderly;
  • identification of common illnesses or trends of illness;
  • identification of high-risk cases for intensive care management; and
  • screening, education and outreach when appropriate. Objective, scientifically-based clinical criteria and treatment guidelines, in the context of provider or member supplied clinical information, guide the utilization management processes.

Participating providers are required to comply with utilization management policies and procedures and associated review processes.

Behavioral Health Care includes:
  • Behavioral health guidelines – Identify the most effective level of care for specific behavioral conditions.
  • Level of care guidelines – Assess a patient’s level of care needs in situations when a diagnosis-specific guideline does not apply.
  • Therapeutic and testing procedures – Provide specific criteria for determining when a procedure, treatment, or diagnostic test may be indicated.
  • Detailed discharge criteria – Focus on specific care elements to consider when discharging patients to a lower level of care.
  • Flexible recovery courses – Manage longer behavioral health episodes with recovery courses listed in care days for inpatient treatments and stages for outpatient treatments.
  • Alternative care planning – Select effective alternative therapies and levels of care based on the specifics of a patient’s case.

Utilization Management Affirmative Statement: 

 All DWIHN, Crisis Service Vendors, and Access Center practitioners and employees who make Utilization Management decisions understand the importance of ensuring that all consumers receive clinically appropriate, humane and compassionate services of the same quality that one would expect for their child, parent, or spouse by affirming the following:
  • Utilization Management (UM) decision-making is based only on appropriateness of care, service, and existence of coverage.
  • DWIHN, The Access Center, and Crisis Service Vendors, do not reward practitioners or other individuals for issuing denials of coverage or service care.
  • No Physicians nor any other staff making UM decisions are rewarded for issuing denials of coverage or service or reducing the provision of care which is deemed medically necessary.


The Program

The UM Program encompasses the management of care from the point of consumer entry through discharge using objective, standardized, and widely-distributed clinical protocols and enhanced outpatient care management interventions. Intensive utilization management activities may be conducted for high-cost, highly restrictive levels of care and cases that represent clinical complexity and risk.

Annually, the DWIHN’s UM Program Description is reviewed and evaluated for overall program effectiveness and its impact is documented within the annual Quality Improvement Program evaluation. The UM Annual Program Evaluation and UM Program Description are also approved on annual basis by the Board of Directors and the UM Committee.

Examples of review activities included in DWIHN’s utilization management program are determinations of:

medical necessity, pre-authorization, certification, notification, concurrent review, retrospective review, provider/utilization management appeals, care/case management, discharge planning and coordination of care.

Medical Necessity

MCG – Medical Necessity Criteria Software for Behavioral Health Care

This new software will be installed and equip Utilization Management, Care Coordinators, and Provider Staff with the implementation of guidelines in Behavioral Health Care. This will help with management of behavioral health care services and ensure behavioral health parity requirements. MCG manages specific psychological, behavioral, and pharmacologic therapies for behavioral health challenges at five levels of care across 15 diagnostic groups.

UM Medical Necessity Criteria

DWIHN uses nationally recognized medical necessity criteria from MCG to assist in making behavioral health utilization management decisions. The criteria are reviewed annually with input from practitioners in our network. Access to the on-line version of the criteria is provided to all contracted providers/practitioners or by means of CD for those providers/practitioners with no access to the internet. 

ASAM criteria is utilized for all substance use disorder decisions.  The ASAM Criteria, Third Edition, is copyrighted but can be purchased by contacting:

American Society of Addiction Medicine
4601 North Park Ave
Upper Arcade Suite 101
Chevy Chase, MD 20815
Telephone: (301) 656-3920 Fax: (301) 656-3815
DWIHN shall provide specific medical necessity criteria to practitioners/providers and enrollees/members and other stakeholders upon request free of charge. Criteria can be requested to be provided by email, fax, mail, in-person or by telephone by calling (888) 490-9698.