Utilization Management Program definition

Utilization Management Program means a program approved by BLUE CROSS and designed to review and manage the utilization of Covered Medical Services.

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Utilization Management Program means the infrastructure required to carry out the 26 concurrent review services according to this Contract including, but not limited to, policies and 27 procedures, request staffing and information systems.

Utilization Management Program means either the utilization management program established and administered or subcontracted by Beech summarized in the Provider Manual or any utilization management program required by a Payor.

Examples of Utilization Management Program in a sentence

However, this Section is not intended to, and will not, restrict any Utilization Management Program established by AvMed.
The UM Director is responsible for overseeing the day-to-day operational activities of the Utilization Management Program in accordance with state guidelines.
The Utilization Management Program shall evaluate medical necessity, appropriateness and efficiency of services provided to Medi-Cal beneficiaries prospectively or retrospectively.
The PH-MCO must receive advance written approval of the list and scope of services to be referred or prior authorized by the Department as outlined in Exhibit H, Prior Authorization Guidelines for Participating Managed Care Organizations in the HealthChoices Program, and Exhibit M(1), Quality Management and Utilization Management Program Requirements.
For written information about Blue Shield’s Utilization Management Program, visit ▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇.

More Definitions of Utilization Management Program

Utilization Management Program means the process designed to review and determine, on a prospective, concurrent, and/or retrospective basis whether the medical procedure provided to a Member pursuant to the terms of the Benefit Healthcare Plan(s) and this Agreement is a Medically Necessary Service.

Utilization Management Program means a strategy designed to ensure that health care expenditures are restricted to those that are needed and appropriate by reviewing patient-inmate medical records through the application of defined criteria or expert opinion, or both. Utilization management assesses the efficiency of the health care process and the appropriateness of decisionmaking in relation to the site of care, its frequency, and its duration through prospective, concurrent, and retrospective utilization reviews.

Utilization Management Program means a system of reviewing the medical necessity, appropriateness, or quality of health care services and supplies provided under a managed care plan using specified guidelines. Such a system may include, but is not limited to, preadmission certification, the application of practice guidelines, continued stay review, discharge planning, preauthorization of ambulatory procedures and retrospective review.

Utilization Management Program means (i) the utilization management program developed, established and administered by PHO or its agents for the determination of the medical necessity of medical services provided to Beneficiaries, (ii) a utilization management program developed by a Payor and administered by PHO, or (iii) a utilization management program developed, established and administered by a Payor.

Utilization Management Program means a utilization management

Utilization Management Program. (UM) means a program approved by COMPANY and designed to review the appropriate utilization of Covered Services provided to Enrollees. -------------------------------------------------------------------------------- OPTIMUM HEALTH SERVICES OF FLORIDA, INC. SPECIALIST PROVIDER AGREEMENT REVISED - 2/15/98 ALL PAGE 10 of 13 -------------------------------------------------------------------------------- ATTACHMENT B SPECIALIST PROVIDER COVERED SERVICES Specialist Covered Services shall include the following: 1.1 Covered Services rendered by SPECIALIST PROVIDER within his/her specialty upon Referral at the SPECIALIST PROVIDER's office or elsewhere when dictated by the need for preventive, diagnostic, or therapeutic care for the treatment of a particular injury, illness, disease, specimen collection, and routine outpatient surgical conditions.

Utilization Management Program means the policies, procedures, and processes whereby APS conducts Utilization Review, as required for the accreditation of managed care organizations by NCQA or other recognized accrediting entity.

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