UTILIZATION REVIEW AND QUALITY ASSURANCE Clause Samples

UTILIZATION REVIEW AND QUALITY ASSURANCE. 1. The INSURER will establish a Quality of Care Program with the following guidelines:

UTILIZATION REVIEW AND QUALITY ASSURANCE. If while completing the Utilization Review and Quality Assurance requirements of this Exhibit A, Attachment I, any of the Contractor’s skilled professional medical and personnel directly supporting staff meet the criteria set forth in 42 CFR 432.50(d)(1), then the Contractor shall submit a written request that specifically demonstrates how the skilled professional medical personnel and directly supporting staff meet all of the applicable criteria set forth in 42 CFR 432.50(d)(1) and outlines the duties they shall perform to assist DHCS, or DHCS’s skilled professional medical personnel, in activities that are directly related to the administration of the DMC Program. DHCS shall respond to the Contractor’s written request within 20 days with either a written agreement pursuant to 42 CFR 432.50(d)(2) approving the request or a written explanation as to why DHCS does not agree that the Contractor’s skilled professional medical personnel and directly supporting staff do not meet the criteria set forth in 42 CFR 432.50(d)(1).

UTILIZATION REVIEW AND QUALITY ASSURANCE. 3.1 Provider shall, and shall cause each Contracting Provider to, actively participate in, support, and cooperate with any applicable utilization management and quality assurance (“UM/QA”) programs designated and approved by March Vision Care or the Plan. March Vision Care may establish one or more committees comprised of Contracting Providers and other individuals licensed to practice optometry and/or ophthalmology for purposes of carrying out the UM/QA programs designated and approved by March Vision Care under this Agreement. March Vision Care shall give Provider access via eyeSynergy® or other means to any applicable documentation of such programs and any amendments or modifications. 3.2 Provider shall (and shall cause each Contracting Provider to) cooperate with and abide by and adhere to rulings of the March Vision Care committees, and further agrees that upon request, Provider will furnish case records of March Vision Care patients for whom claims have been submitted, and that March Vision Care may use any information so obtained for statistical, actuarial, scientific, peer review or other reasonable purposes, provided that the committee shall maintain the confidentiality of such information in accordance with applicable State and federal laws and regulations.

UTILIZATION REVIEW AND QUALITY ASSURANCE. Provider shall cooperate fully with Plan’s Utilization Review and Quality Assurance Programs or such other Utilization Review and Quality Assurance Programs designated by Plan as set forth in the Provider Handbook. Failure to do so shall be deemed a material breach of this Agreement.

UTILIZATION REVIEW AND QUALITY ASSURANCE. 1. The MBHO will establish a Quality of Care Program with the following guidelines: a) PHYSICIAN-CREDENTIALING: The MBHO will establish and follow strict provider screening procedures before contracting. These procedures should substantially conform to current NCQA (National Commission for Quality Assurance) guidelines. In order to assure quality health services for the medically indigent, the MBHO will follow stringent physician selection and credentialing process for this plan as per the MBHO's Proposal. The ADMINISTRATION may review participating providers credentials at any time after reasonable notice and submit its findings to the MBHO for consideration by the MBHO if necessary. The MBHO shall notify the ADMINISTRATION quarterly of all accepted and non-accepted providers.

UTILIZATION REVIEW AND QUALITY ASSURANCE. Employee shall practice in a manner consistent with, and remain subject to, any utilization or quality assurance review processes which Employer may institute in regard to its