Common use of Quality Assurance and Utilization Review Clause in Contracts

Quality Assurance and Utilization Review. PROVIDER shall cooperate with the quality assurance and utilization review system established pursuant to Section 5179 of the California Labor Code and Section 1979 of the Rules, and shall cooperate with the Commissioner in accordance with the provisions of Section 5186 of the California Labor Code and Sections 1986 and 1986.1 of the Rules and the policies and related procedures established by IEFMC. 8.1 All treatment provided under the Workers’ Compensation Network shall be provided in accordance with the medical treatment utilization schedule established pursuant to Section 5307.27 of the American College of Occupational & Environmental Medicine’s (ACOEM) Occupational Medicine Practice Guidelines as well as any other requirements under the labor code. 8.2 For Patients being seen under Workers’ Compensation, “Medically Necessary Services” are those services that are determined to be appropriate and necessary for the symptoms, diagnosis or treatment of the medical condition, and provided for the diagnosis or direct care and treatment of the medical condition, and within standards of good medical practice with the organized community, and not primarily for the convenience of the injured worker, the physician, or any other provider’s convenience, and be the most appropriate level of service which can be safely provided. 8.3 For Patient’s being seen under Workers’ Compensation “Utilization Schedule” means the adoption by the Administrative Director of a utilization schedule presumptively correct on the issue of extent and scope of medical treatment. These guidelines are currently based on the American College of Occupational and Environmental Medicine and Occupational Medical Practice Guidelines. For injuries not covered by the ACOEM guidelines or the schedule, treatment shall be in accordance with other evidence-based medical treatment guidelines generally recognized by the medical community.