Vermont § 2031 - Creation of Clinical Utilization Review Board

§ 2031. Creation of Clinical Utilization Review Board

• (a) No later than June 15, 2010, the Department of Vermont Health Access shall create
  a Clinical Utilization Review Board to examine existing medical services, emerging
  technologies, and relevant evidence-based clinical practice guidelines and make recommendations
  to the Department regarding coverage, unit limitations, place of service, and appropriate
  medical necessity of services in the State’s Medicaid programs. (b) The Board shall comprise 10 members with diverse medical experience, to be appointed
  by the Governor upon recommendation of the Commissioner of Vermont Health Access.
  The Board shall solicit additional input as needed from individuals with expertise
  in areas of relevance to the Board’s deliberations. The Medical Director of the Department
  of Vermont Health Access shall serve as the State’s liaison to the Board. Board member
  terms shall be staggered, but in no event longer than three years from the date of
  appointment. The Board shall meet at least quarterly, provided that the Board shall
  meet no less frequently than once per month for the first six months following its
  formation. (c) The Board shall have the following duties and responsibilities: (1) Identify and recommend to the Commissioner of Vermont Health Access opportunities
  to improve quality, efficiencies, and adherence to relevant evidence-based clinical
  practice guidelines in the Department’s medical programs by: (A) examining high-cost and high-use services identified through the programs’ current
  medical claims data; (B) reviewing existing utilization controls to identify areas in which improved utilization
  review might be indicated, including use of elective, nonemergency, out-of-state outpatient
  and hospital services; (C) reviewing medical literature on current best practices and areas in which services
  lack sufficient evidence to support their effectiveness; (D) conferring with commissioners, directors, and councils within the Agency of Human
  Services and the Department of Financial Regulation, as appropriate, to identify specific
  opportunities for exploration and to solicit recommendations; (E) identifying appropriate but underutilized services and recommending new services for
  addition to Medicaid coverage; (F) determining whether it would be clinically and fiscally appropriate for the Department
  of Vermont Health Access to contract with facilities that specialize in certain treatments
  and have been recognized by the medical community as having good clinical outcomes
  and low morbidity and mortality rates, such as transplant centers and pediatric oncology
  centers; and (G) considering the possible administrative burdens or benefits of potential recommendations
  on providers, including examining the feasibility of exempting from prior authorization
  requirements those health care professionals whose prior authorization requests are
  routinely granted. (2) Recommend to the Commissioner of Vermont Health Access the most appropriate mechanisms
  to implement the recommended evidence-based clinical practice guidelines. Such mechanisms
  may include prior authorization, prepayment, postservice claim review, and frequency
  limits. Recommendations shall be consistent with the Department’s existing utilization
  processes, including those related to transparency, timeliness, and reporting. Prior
  to submitting final recommendations to the Commissioner of Vermont Health Access,
  the Board shall ensure time for public comment is available during the Board’s meeting
  and identify other methods for soliciting public input. (d) The Commissioner may adopt a mechanism recommended pursuant to subdivision (c)(2)
  of this section with or without amendment, provided that if the Commissioner proposes
  to amend the mechanism recommended by the Board, he or she shall request the Board
  to consider the amendment before the mechanism is implemented or is filed as a proposed
  administrative rule pursuant to 3 V.S.A. § 838. (Added 2009, No. 146 (Adj. Sess.), § C34; amended No. 156, § F.7; 2011, No. 78 (Adj. Sess.), § 2, eff. April 2, 2012.)