Common use of Utilization Management Clause in Contracts

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. (a) The Network Service Provider shall develop and implement utilization management strategies that shall, at minimum, address the following areas: a. 1. Delivery of quality, clinically necessary services to eligible individuals in a timely fashion; b. 2. Improvement of clinical outcomes; c. 3. Guidelines, standards, and criteria set by regulatory and accrediting agencies are adhered to, as appropriate, for the client population; d. 4. Clinical evidence is used to make utilization management decisions, taking into account the local SOC and the individual’s circumstances; and e. 5. The utilization management strategies are integrated with the Network Service Provider’s Continuous Quality Improvement (CQI) activities.