Appropriation ID - 15000 Global Commitment

The Clinical Services Team (CST)

Please note that in the summer of 2020, the Clinical Integrity Unit, Clinical Operations Unit, and the Pharmacy unit, merged and became the Clinical Services Team.  

The Clinical Integrity Unit (CIU) is responsible for the utilization management of mental health and detoxification services. The team works toward the integration and coordination of services provided to Vermont Medicaid members with substance use disorders and mental health needs. The team performs utilization management activities; including concurrent review and authorization of mental health, eating disorder treatment, and substance use detoxification services. The CIU also administers the Team Care program, which locks a member to a single prescriber and a single pharmacy. In addition, the Autism Specialist authorizes applied behavior analysis (ABA) services for children.  The CIU also engages in Medical Record Reviews to support quality initiatives.

The Clinical Operations Unit (COU) monitors the quality, appropriateness, and effectiveness of healthcare services requested by providers for members:

• requests for services are reviewed and processed efficiently and within the timeframes outlined in Medicaid Rule;
• over-and-under utilization of healthcare services is identified through the prior authorization (PA) review process and case tracking;
• clinical criteria for certain established clinical services, new technologies and medical treatments are developed and/or adopted;
• medical benefits are correctly coded;
• provider appeals are reviewed;
• provider education is offered related to specific Medicaid policies and procedures;
• quality improvement activities are performed to enhance medical benefits for members.

• Department of Mental Health Adult and Children and Families Units,
• Department of Disabilities, Aging and Independent Living,
• Department for Children and Families,
• Integrated Family Services,
• Designated Hospitals,
• Designated Agencies,
• Special Service Agencies,
• Vermont Chronic Care Initiative

The CIU serves Vermont Medicaid members who require mental health inpatient and detoxification services, eating disorder treatment, and ABA services.

One of the main roles of the COU is reviewing prior authorization requests for medical necessity. These requests are for services or goods (examples: durable medical equipment, elective inpatient admissions, out of network office visits) for members. The COU also serves the provider community, by providing education to support clinical review processes, so DVHA can better serve Vermont Medicaid members and the provider community.