Clinical Care and Extended Care Review Policy

SUD Specialty Group – CA, Mental Health Specialty Group, P.A., Mental Health Specialty Group NJ, PC, and Mental Health Specialty Group KS, P.A. (collectively, “Group”) contracts with Path, CCM, Inc. d/b/a Rula (“Rula”) for management and administrative support services. Each entity within the Group and Rula may be referenced herein as a Company and, collectively, as the Companies.

Policy Statement

This policy develops a standardized clinical care and extended care review process to assess and make a recommendation  on  the need for ongoing care for a patient seen by a Group provider.   The purpose of this review is to facilitate the provision of high quality and efficient behavioral health care services to patients and providers through monitoring, evaluating, measuring, and supporting processes which impact the delivery of services. 

Applicability:

This policy applies to all team members. For purposes of this policy, the Companies’ team members include individuals who would be considered part of the workforce, such as employees, independent contractors, and other persons whose work performance is under the direct purview of the Companies’  business practices. 

Definitions

Clinical care review (CCR): a standardized process of review of a medical record by a trained, qualified, independently licensed social worker, psychologist, marriage and family therapist or professional counselor with the clinical expertise and training to conduct an evaluation of documentation. The reviewer will not be associated with the patient so as to provide an unbiased evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services. This also reviews instances of ‘extended care’ where duration of sessions is longer than the expected average. 

Provider: an individual who is qualified by licensure and experience to provide services to patients and who is employed or contracted by the Group to provide those services

Medical necessity:  health care services that a Provider, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, and that are: (a) in accordance with generally accepted standards of clinical practice; (b) clinically appropriate, in terms of type, frequency, extent, and duration, and considered effective for the patient’s illness; and (c) not primarily for the convenience of the patient or Provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic results as to the diagnosis or treatment of that patient’s illness. 

Generally accepted standards of medical practice:  standards that are based on credible scientific evidence published in peer-reviewed clinical literature generally recognized by the relevant therapeutic community, Provider specialty association recommendations, and the views of Providers practicing in relevant clinical areas and any other relevant factor.

Policy

A. Clinical care and extended care review protections.

1. Clinical care reviews are a quality activity, the confidentiality of which is protected by HIPAA.  Clinical care reviews are used for ongoing quality improvement efforts related to the necessity, appropriateness, or quality of services rendered to a patient. 
2. The record of the clinical care review, including but not limited to, the associated clinical care review form, the data collected, and the resulting reports, findings, and conclusions are confidential and are not part of the designated record set. 
3. As part of the quality process, payers may review clinical care review determinations upon request.  

B. Clinical care reviews and extended care reviews may be completed or requested for various reasons, including, but not limited to: 

1. Findings from a peer review or chart audit; 
2. A patient, family member or patient advocate request;
3. A complaint or Grievance brought to the attention of the Quality team; 
4. A provider request for ongoing services; 
5. A payer request; 
6. Group finding of a patient’s lack of progress over two consecutive measurements; 
7. Anytime service delivery concerns are brought to the attention of the Quality team. 

C. Clinical care reviews and extended care reviews are always concurrent reviews which are completed during the patient’s course of treatment.  There are two portions of concurrent reviews that are used to make a determination: 

1. Patient-level data, based on quantitative information captured during the course of treatment; and 
2. A standardized qualitative assessment of medical necessity that is determined by clinical review of documentation associated with recent clinical encounters. The clinical review is first completed by an AI chart review tool. In cases with ambiguous results, a secondary review is conducted by a clinical care reviewer.  

D. Documentation of review and results

1. Clinical care review findings will be documented in a standardized format using an internal CCR Tracking Sheet.
2. Results of clinical care reviews will be sent to the treating provider for the purpose of quality/practice improvement and clinical efficacy. The information contained in the clinical care review is expected to be incorporated into clinical decision making related to the ongoing need for care provided to the patient. 

E. Tracking of clinical care reviews and extended care reviews 

1. The Quality team will maintain a database of all completed reviews for a period of 2 years after the date of the most recent review. 
2. The Quality team will conduct trend analysis of aggregate data and provider-level analysis for the purposes of quality improvement.   

Attachments: 

None

Updated January 05, 2026 20:26