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 SFY24 priorities:

• Develop and formalize a CST Data Reporting Book.
• Utilize DVHA resources to support continued unification of CST.
• Review and monitor procurement activities.
• Continue to monitor and refine current CST exceptions request performance measure.
• Engage in weight loss/ healthy lifestyle project.

CIU SFY24 priorities:

• Continue to monitor and assess Emergency Department Per Diem for Extended Mental Health Stays.
• Monitor and support the ABA Value Based payment project.
• Continue to monitor quality of care for inpatient psychiatric treatment for VT Medicaid members.                           
• Explore provider network to enhance and stabilize ABA services.

COU SFY24 priorities:

• Eliminating “I” status associated with PA process with real time PA processing systems
• Refining DVHA Fee Schedule
• Comprehensive Pain Pilot
• Identification of storage & delivery modality of expensive and or complex DME
• Advance Palliative Care Program

Pharmacy SFY24 priorities:

• Focus on Value based agreements
• Improve/Upgrade 340 B process
• Mandatory 90 Day PA form
• Continue NASPO Project Work