Clinical Services Team: Clinical Operations Unit

What We Do

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

The COU ensures that:

  • 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.

Please note that in the Summer of 2020, the Clinical Operations Unit, the Pharmacy Unit, and the Quality & Clinical Integrity Unit came together as the Clinical Services Team.  The Units are displayed separately in this scorecard due to their different lines of work.

Who We Serve

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 our beneficiaries.

The COU also serves our provider community, as we help support them by providing education around our processes, so we can better serve our beneficiaries.

How We Impact

The COU processed almost 16,000 prior authorization requests in calendar year 2019.  Decisions are based on Vermont Medicaid Rule 7102 – this in brief is medical necessity and least expensive, appropriate health service.  COU's priority is that our beneficiaries get what is medically appropriate while being fiscally responsible.

Action Plan

SFY22 priorities are:

  • Development of the Clinical Liaison role and work within the COU to support DVHA’s clinical and payer requirements to improve care coordination.
  • Development of a cost benefit analysis to determine financial impact, with the goal of developing an Adult Palliative Care Program in SFY 2023 , beginning with Pediatric Palliative Care members who are aging out of their program and include adults with end stage congestive heart failure who are not eligible or ready to choose hospice care.  A value- based payment project.
  • Implementation and expansion of the Clinical Audit scope of work to support utilization management strategies specific to evaluating utilization and clinical outcomes for services no longer requiring prior authorization and to support policy, reimbursement, and clinical determinations within DVHA


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