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.

The Pharmacy Unit is responsible for managing all aspects of Vermont’s publicly funded pharmacy benefits programs. The pharmacy unit oversees the contract with DVHA’s pharmacy benefits manager (PBM) Change Healthcare. Together with its PBM, the Pharmacy Unit is responsible for: working with pharmacies, prescribers and members and resolving all drug-related issues; processing over 2 million pharmacy claims annually, facilitating appeals related to prescription drug coverage within the pharmacy benefit; making drug coverage determinations for pharmacy claims and physician-administered drugs; assisting with drug appeals and exception requests; overseeing federal, state, and supplemental drug rebate programs ; overseeing and managing the Drug Utilization Review Board; managing DVHA’s preferred drug list (PDL); and conducting pharmacy utilization management programs and drug utilization review activities focused on promoting rational prescribing practices and alignment with evidence-based clinical guidelines. The Pharmacy Unit enforces coverage rules in compliance with federal and state laws and implements legislative and operational changes to the pharmacy benefit programs as needed.  The Pharmacy unit also implements new programs and policies that support value-based payments and pharmacist clinical services. For example, the Unit implemented a payment structure for pharmacists performing Medication Therapy Management (MTM) activities and policies and procedures to support COVID testing and vaccinations by pharmacists during the Public Health Emergency.  

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.

The Pharmacy Unit's primary stakeholders are Vermont Medicaid enrolled members, prescribers, and pharmacies. The unit also interacts with many other internal and external stakeholders such as other units within DVHA, other departments within the Agency of Human Services, various legislative committees, pharmaceutical manufacturers, and others.

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.

The Pharmacy Unit's primary stakeholders are Vermont Medicaid enrolled members, prescribers, and pharmacies. The unit also interacts with many other internal and external stakeholders such as other units within DVHA, other departments within the Agency of Human Services, various legislative committees, pharmaceutical manufacturers, and others.

CST SFY23 Priorities:

• Development of Clinical Services Team (CST) Performance Scorecard Measure: Exceptions Requests
• Develop and implement an integrated and coordinated prior authorization process between the DVHA Pharmacy Unit, DVHA Pharmacy vendor, Change Healthcare, and the Clinical Operations Unit to support medical necessity review and prior authorization requests for medications requiring inpatient, elective office visits, and/or out of network clinical review for medication administration
• Development the clinical liaison work within the Clinical Services Team & include the advisory of the DVHA Chief Medical Officer to support DVHA’s clinical & payer requirements to improve care coordination & provide consultation and advisory direction to other units on a project basis to support shared objectives and align work
• Utilize DVHA resources to support further unification of the Clinical Services Team

CIU SFY23 priorities:

• Continue to expand VT Medicaid enrolled provider network for eating disorder treatment
• Emergency department per diem rate for extended mental health stays
• Monitor quality of care for inpatient psychiatric treatment for VT Medicaid members

COU SFY23 priorities:

• Implement the Clinical Liaison work to support DVHA’s clinical & payer requirements
• Develop and adopt a palliative care program
• Continue the work of Clinical Audits and expand to include the Clinical Services Team
• Engage in the work of increasing access to dental services as evidenced by; review of dental rates, increased dental provider network, & support of programmatic efforts targeted at specific populations (Adult Disabled population, Team Care) to support appropriate utilization & delivery of dental services.

Pharmacy SFY23 priorities:

• Hep C Treatment in HUBS
• NASPO Project: PBA/PBM RFP & acquisition of new contract
• Drug Rebate and Coverage policies for High-Cost Drugs