Managed Care Program Clause Samples
The Managed Care Program clause defines the framework and requirements for how healthcare services are delivered and reimbursed under a managed care arrangement. Typically, this clause outlines the obligations of providers to adhere to specific cost-control measures, such as using a network of approved providers, obtaining pre-authorizations for certain treatments, and following established care protocols. Its core practical function is to control healthcare costs and improve care coordination by setting clear rules for service delivery and payment within the managed care system.
Managed Care Program. SHL's Managed Care Program, using the services of professional medical peer review committees, Utilization Review Committees, and/or the Medical Director, determines whether services and supplies are Medically Necessary. The Managed Care Program helps direct care to the most appropriate setting to provide healthcare in a cost-effective manner. Benefits payable for expenses incurred in connection with Covered Services, which are not Prior Authorized by the Managed Care Program, will be reduced as shown in the Attachment A Benefit Schedule.
Managed Care Program. This section tells you about SHL’s Managed Care Program and which Covered Services require Prior Authorization.
Managed Care Program. HPN's Managed Care Program, using the services of professional medical peer review committees, utilization review committees, and/or the Medical Director, determines whether services and supplies are Medically Necessary. HPN’s Managed Care Program helps direct the patient to the most appropriate setting to provide healthcare in a cost-effective manner.
Managed Care Program. This section tells you about HPN’s Managed Care Program and which Covered Services require Prior Authorization.
Managed Care Program. CarePlus plans to participate in various types of Programs, government contracts and enter into corresponding Payor and Subscriber Agreements. Innovative agrees to participate in all of the Programs described in the Exhibits annexed hereto and made a part hereof. The terms of any Program and corresponding Payor Agreements shall be consistent with the terms of this Agreement except as identified in the applicable Exhibit. To the extent that there is a conflict between this Agreement and an Exhibit, the Exhibit shall prevail.
Managed Care Program. If the services are Medically Necessary and/or appropriate. The appropriateness of the proposed setting. The required duration of treatment or admission.
Managed Care Program. Louisiana Medicaid program providing Medicaid covered services to enrollees through select MCOs with the goal of effectively utilizing resources to promote the health and well-being of Louisianans.
Managed Care Program. This section tells you about SHL’s Managed Care Program and which Covered Services require Predetermination.
3.1 Managed Care Program
Managed Care Program. Contractor shall be responsible for making and maintaining contracts with a variety of providers and networks for services covered under the Contract to deliver prompt and appropriate medical care to City’s injured employees at the rates contained in this Contract, Attachment E - Discount Rates and Fees or as explicitly agreed to by City management or designee(s). City of Los Angeles Managed Care Program is designed to:
1. Protect the health and safety of City employees.
2. Provide immediate and appropriate quality medical care.
3. Return injured workers to duty in a safe, productive, and timely manner.
4. Provide these benefits at a reasonable cost to City.
5. Ensure compliance with all applicable State Workers’ Compensation Laws.
6. Prevent Fraud.
7. Increase the efficiency of the Workers’ Compensation Analyst. Contractor shall provide monthly, quarterly, and annual savings reports that clearly demonstrate savings below fee schedule and other discounts.
Managed Care Program. If the services are Medically Necessary and/or appropriate. • The appropriateness of the proposed setting. • The required duration of treatment or admission. Following review, HPN will complete the Prior Authorization form and send a copy to the Provider and the Member. The form will specify approved services and supplies. Prior Authorization is not a guarantee of payment.