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Clinical Utilization Review Board

The Clinical Utilization Review Board (CURB) was established by Act 146 Sec. C34. 33 V.S.A. chapter 19, subchapter 6 during the 2010 legislative session. The Department of Vermont Health Access (DVHA) was tasked to create the CURB to examine existing medical services, emerging technologies, and relevant evidence-based clinical practice guidelines and make recommendations to DVHA regarding coverage, unit limitations, place of service, and appropriate medical necessity of services in the state’s Medicaid programs.

The CURB is comprised of 10 members with diverse medical experience, appointed by the Governor upon recommendation of the Commissioner of the Department of Vermont Health Access (Commissioner). The CURB will solicit additional input as needed from individuals with expertise in areas of relevance to the Board’s deliberations. The Medical Director of DVHA serves as the State’s liaison to CURB.

The CURB has the following duties and responsibilities:

(1) Identify and recommend to the Commissioner opportunities to improve quality, efficiencies, and adherence to relevant evidence-based clinical practice guidelines in the Department’s medical programs by:

(a) examining high-cost and high-use services identified through the programs’ current medical claims data;
(b) reviewing existing utilization controls to identify areas in which improved utilization review might be indicated, including use of elective, nonemergency, out-of-state outpatient and hospital services;
(c) reviewing medical literature on current best practices and areas in which services lack sufficient evidence to support their effectiveness;
(d) conferring with commissioners, directors, and councils within the Agency of Human Services and the Department of Banking, Insurance, Securities, and Health Care Administration, as appropriate, to identify specific opportunities for exploration and to solicit recommendations;
(e) identifying appropriate but underutilized services and recommending new services for addition to Medicaid coverage;
(f) determining whether it would be clinically and fiscally appropriate for DVHA to contract with facilities that specialize in certain treatments and have been recognized by the medical community as having good clinical outcomes and low morbidity and mortality rates, such as transplant centers and pediatric oncology centers; and
(g) considering the possible administrative burdens or benefits of potential recommendations on providers, including examining the feasibility of exempting from prior authorization requirements those health care professionals whose prior authorization requests are routinely granted.

(2) Recommend to the Commissioner the most appropriate mechanisms to implement the recommended evidence-based clinical practice guidelines. Such mechanisms may include prior authorization, prepayment, post service claim review, and frequency limits.