- To define the process for developing and adopting clinical practice guidelines.
- To ensure that Health Share/Tuality Health Alliance (THA) makes the Clinical Practice Guidelines used in THA Medical Management utilization/medical necessity referral determinations known to THA Providers.
- To ensure that THA provides more than one avenue of dissemination of Clinical Practice Guidelines to providers and/or members. (THA Website and information sent via email/mail)
- To ensure that practitioners and members make decisions about appropriate healthcare for specific clinical circumstances.
The THA Quality Management Committee (QMC) is responsible for the review, adoption, and approval of clinical practice guidelines. This QMC process includes the development and dissemination of clinical practice guidelines adopted from nationally recognized sources, with solicitation for comments from the THA Medical Director and QMC members.
- Alignment of care
Clinical practice guidelines may be used primarily to standardize care for a specific condition among providers throughout the THA network. THA engages in an active process of choosing guidelines that are appropriate to its membership and uses these guidelines as the standard to measure performance. THA recognizes that the benefits of promoting guidelines for use include:
- Decreasing variations in practice patterns;
- Increasing appropriateness of care;
- Improving health outcomes and health status;
- Reducing overall cost of care
- Referral and Authorization Decisions
Clinical practice guidelines may be used primarily for outlining the criteria for making referral and authorization decisions. If THA does not have its own guidelines for a specific condition or treatment, including medications, the following sources will be used
- Guidelines from the Oregon Health Service Commission (for certain conditions or treatments and for determining medical necessity)
- Oregon Health Authority PA Criteria (for medication requests)
- McKesson InterQual Guidelines (for inpatient requests)
- Evidence-based clinical resources such as UpToDate (for determining medical necessity and standard of care).
- Adoption of Clinical Practice Guidelines
THA adopts practice guidelines that meet the following requirements:
- Are based on valid and reliable clinical evidence or a consensus of providers in the particular field.
- Consider the needs of the THA members or potential enrollees.
- Are adopted in consultation with contracting health care professionals.
- Are reviewed and updated periodically as appropriate.
- Dissemination of Clinical Practice Guidelines
The guidelines are located and available for dissemination electronically on the THA Web site (www.tualityhealthalliance.org). An electronic or hard copy of the guidelines will be supplied by THA staff upon request to providers, members, member representatives, and potential enrollees.
- In the event that a member/member’s representative or a potential enrollee requests a copy of the guidelines used in making a referral or authorization decision, the guidelines will be printed and mailed or a file may be sent electronically, whichever method is preferred by the member. If a provider prefers a printed copy of the guidelines, these can be printed and faxed or mailed per the provider’s request.
- Once guidelines are provided, documentation is logged in the Case Management log.
- Guidelines are reviewed and updated as needed, at a minimum every two years.
January 2018 Health Share RAE Participation Agreement
NCQA Clinical Practice Guidelines
Oregon Health Authority Health Plan Services Contract
To ensure that before Tuality Health Alliance (THA) members are referred for back surgery, conservative measures have been tried and failed and that members are in the an optimal state of health to increase likelihood of positive outcomes.
PRIOR AUTHORIZATION REQUIRED
- Spinal Surgery is indicated for a variety of conditions with requirements mentioned within the prioritized list and its associated guideline notes. These conditions typically fall under “Conditions of the back and spine with urgent surgical indications2” and refer to the Guideline Note “Surgical interventions for conditions of the back and spine other than scoliosis2” for requirements to be approved for both decompressive surgery and spinal fusion, this guideline note also addresses interventions that are not covered.
- Initial management should be conservative modalities with active participation by the member including medication, physical therapy, acupuncture, or chiropractic medicine as appropriate. A 6-8 week course of conservative care is usually recommended prior to surgical consultation unless there are contraindications to conservative therapy.
- THA providers are required to provide evidence that members who request spinal fusion surgery are not currently smoking due to the higher incidence of adverse effects for smokers post-surgery1,4. For never or former smokers this includes one negative lab test at any point, for current or recent former smokers (quit within the last year) this involves a series of two negative lab tests, one six months before surgery, and one within the month prior to surgery 3,4.
These tests are Nicotine / Cotinine levels, and can be ordered through Tuality lab facilities. These results should be included in any prior authorization request for spinal surgery that is non-emergent. The test results may take up to two weeks to result.
- Kong, L., Liu, Z., Meng, F., & Shen, Y. (2017) Smoking and Risk of Surgical Site Infection after Spinal Surgery: A Systematic Review and Meta-Analysis. Retrieved
- Guideline Note 37 “Surgical Interventions for conditions of the back and spine other than scoliosis”
- Guideline Note 100 “Smoking and Spinal Fusion”
- Guideline Note A4 “Smoking cessation and elective surgical procedures”
A neuropsychological examination assesses the clinical relationship between the brain and cognitive/behavioral dysfunction.
- Neuropsychological testing may be covered when furnished by preferred providers or with a valid arrangement by a non-contracted provider in conjunction with a qualifying diagnosis and treatment plan. The Oregon Health Plan Prioritized List defines the diagnoses that are covered. Additional considerations to identify medical necessity include the following:
- For severe/moderate head injury with persistent symptoms, a qualifying diagnosis OR documentation of persistence of symptoms related to the injury is required.1
- For autism spectrum disorders, a qualifying diagnosis OR documentation of high level of clinical suspicion for autism is required.
- For chronic organic mental disorders including dementias2, a qualifying diagnosis OR documentation of a high level of clinical suspicion for an organic brain disease OR documentation of history of chemotherapy with high risk of neurotoxicity in pediatric patients is required3.
- Prior authorization is required and all codes must be on the most current fee schedule.
- If there is the presence or possibility of a psychiatric or behavior disorder, the member must first be evaluated by a qualified behavioral health provider. If behavioral health evaluation does not identify psychiatric or behavioral cause for the symptoms, the member will need re-evaluation by referring provider to determine need for neuropsychological evaluation.
- Testing for developmental delay must be done through existing programs within the education system, including the Early Intervention program and the public school system. Children with specific risk factors requiring neuropsychiatric testing, such as extremely low birthweight (ELBW), should be evaluated and monitored through a formal developmental pediatrics program.
- Coverage of testing is excluded when purpose is not health-related and will not change healthcare related diagnosis and management. Examples of excluded purposes include, but are not limited assessing academic potential, learning disabilities or ADHD4; determinations of disability, legal competency or job placement; personal injury evaluation; and general screening.
- Harmon, K., Drezner, J., Gammons, M., et al. (2013). American Medical Society for Sports Medicine Position Statement: Concussion in Sport. Clinical Journal of Sport Medicine. 23:1
- Practice Guideline Update: Mild Cognitive Impairment. (2018) American Academy of Neurology. Retrieved from https://www.aan.com/Guidelines/home/GetGuidelineContent/882
- Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent, and Young Adult Cancers. (2013). Children’s Oncology Group. Retrieved from www.survivorshipguidelines.org
- Hall, C.L., Valentine, A.Z., Groom, M.J. et al. (2015). The clinical utility of the continuous performance test and objective measures of activity for diagnosing and monitoring ADHD in children: a systematic review. European Child & Adolescent Psychiatry 25: 677.
|Revised||October 2018 – QMC 10/18/18|