Utilization Management Sample Clauses

Utilization Management. Contractor shall maintain a utilization management program that complies with applicable laws, rules and regulations, including Health and Safety Code § 1367.01 and other requirements established by the applicable State Regulators responsible for oversight of Contractor.

Utilization Management. The Contractor shall maintain a utilization management plan and procedures consistent with the following: Staffing of all utilization management activities shall include, but not be limited to, a medical director, or medical director‘s designee. The Contractor shall also have a medical director‘s designee for Behavioral Health utilization management. All of the team members shall: Be in compliance with all federal, State, and local professional licensing requirements; Include representatives from appropriate specialty areas. Such specialty areas shall include, at a minimum, cardiology, epidemiology, OB/GYN, psychiatry, and substance use disorders; Have at least two (2) or more years of experience in managed care or peer review activities, or both; Not have had any disciplinary actions or other type of sanction ever taken against them, in any state or territory, by the relevant professional licensing or oversight board or the Medicare and Medicaid programs; and Not have any sanctions relating to his or her professional practice including, but not limited to, malpractice actions resulting in entry of judgment against him or her, unless otherwise agreed to by EOHHS; In addition to the requirements set forth in Section 2.9.4.4, the medical director‘s designee for Behavioral Health utilization management shall also: Be board-certified or board-eligible in psychiatry; and Be available twenty-four (24) hours per day, seven days a week for consultation and decision-making with the Contractor‘s clinical staff and providers. The Contractor shall have in place policies and procedures that at a minimum: Routinely assess the effectiveness and the efficiency of the utilization management program; Evaluate the appropriate use of medical technologies, including medical procedures, diagnostic procedures and technology, Behavioral Health treatments, pharmacy formularies and devices; Target areas of suspected inappropriate service utilization; Detect over- and under-utilization; Routinely generate provider profiles regarding utilization patterns and compliance with utilization review criteria and policies; Compare Enrollee and provider utilization with norms for comparable individuals and Network Providers; Routinely monitor inpatient admissions, emergency room use, ancillary, out-of-area services, and out-of-network services, as well as Behavioral Health inpatient and outpatient services, diversionary services, and ESPs; Ensure that treatment and discharge planning are addr...

Utilization Management. (a) The Network Service Provider shall develop and implement utilization management strategies that shall, at minimum, address the following areas: a. Delivery of quality, clinically necessary services to eligible individuals in a timely fashion; b. Improvement of clinical outcomes; c. Guidelines, standards, and criteria set by regulatory and accrediting agencies are adhered to, as appropriate, for the client population; d. Clinical evidence is used to make utilization management decisions, taking into account the local SOC and the individual’s circumstances; and e. The utilization management strategies are integrated with the Network Service Provider’s Continuous Quality Improvement (CQI) activities.

Utilization Management. Case management means a care management plan developed for a Member whose diagnosis requires timely coordination. All benefits, including travel and lodging, are limited to Covered Services that are Medically Necessary and set forth in the EOC. KFHPWA may review a Member's medical records for the purpose of verifying delivery and coverage of services and items. Based on a prospective, concurrent or retrospective review, KFHPWA may deny coverage if, in its determination, such services are not Medically Necessary. Such determination shall be based on established clinical criteria and may require Preauthorization. KFHPWA will not deny coverage retroactively for services with Preauthorization and which have already been provided to the Member except in the case of an intentional misrepresentation of a material fact by the patient, Member, or provider of services, or if coverage was obtained based on inaccurate, false, or misleading information provided on the enrollment application, or for nonpayment of premiums.

Utilization Management. The process of evaluating the necessity, appropriateness and efficiency of health care services against established guidelines and criteria.

Utilization Management. State law requires that health plans disclose to Members and health plan providers the process used to authorize or deny health care services under the plan. Blue Shield has completed documentation of this process as required under Section 1363.5 of the California Health and Safety Code. The document describing Blue Shield’s Utilization Management Program is available online at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ or Members may call the Customer Service Department at the number provided on the back page of this Evidence of Coverage to request a copy.

Utilization Management. Pre-service, concurrent or retrospective review which determines the Medical Necessity of hospital and skilled nursing facility admissions and selected Health Care Services provided on an outpatient basis.

Utilization Management a process of evaluating and determining coverage for, and appropriateness of, medical care services and Behavioral Health Services, as well as providing needed assistance to clinicians or patients, in cooperation with other parties, to ensure appropriate use of resources, which can be done on a prospective or retrospective basis, including service authorization and prior authorization.

Utilization Management. A. The Contractor shall operate a Utilization Management Program that is responsible for assuring that beneficiaries have appropriate access to specialty mental health services as required in California Code of Regulations, title 9, section 1810.440(b)(1)-(3). B. The Utilization Management Program shall evaluate medical necessity, appropriateness and efficiency of services provided to Medi-Cal beneficiaries prospectively or retrospectively. C. Compensation to individuals or entities that conduct utilization management activities must not be structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any beneficiary. (42 C.F.R. § 438.210(e).) D. The Contractor may place appropriate limits on a service based on criteria applied under the State Plan, such as medical necessity and for the purpose of utilization control, provided that the services furnished are sufficient in amount, duration or scope to reasonably achieve the purpose for which the services are furnished. (42 C.F.R. § 438.210(a)(4)(i), (ii)(A).)