Utilization Management Programs definition

Utilization Management Programs means those comprehensive initiatives that are designed to validate medical appropriateness, including Medical Necessity, and to coordinate Covered Services and supplies, including: a. concurrent review of all patients hospitalized in acute care, psychiatric, rehabilitation, and Skilled Nursing Facilities, including on-site review when appropriate; b. case management and discharge planning for all inpatients and those requiring continued care in an alternative setting (such as home care or a Skilled Nursing Facility) and for outpatients when deemed appropriate; and c. prospective reviews for select Health Care Services to ensure that services are Medically Necessary Covered Benefits under this Contract.
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Utilization Management Programs means programs and activities, including, but not limited to, those identified in Appendix B of this Agreement and the Pricing Schedule, designed for the purpose of improving health and safety of Enrollees who purchase Covered Drugs, promoting cost savings and, where appropriate, encouraging the dispensing of Covered Drugs that are chemically different but deemed therapeutically similar to the Drug prescribed, and similar activities with like objectives.
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Examples of Utilization Management Programs in a sentence

  • We have established (and from time to time establish) various Member-focused health education and information programs as well as benefit Utilization Management Programs and utilization review programs.

  • We have established (and from time to time establish) various Member- focused health education and information programs as well as benefit Utilization Management Programs and utilization review programs.

  • Utilization Management Programs include concurrent, retrospective and prospective review of certain services and procedures to assure that care is delivered in the most appropriate setting and is Medically Necessary.

  • The Board and the Union agree that on July 1, 2020, the Express Scripts, Inc.’s Advanced Utilization Management Programs (“ESI-AUM Programs”) shall become effective for all covered members and their dependents.

  • The Plan will maintain and Practitioner agrees to cooperate with the Plan’s Quality Improvement, Claims, Member Grievance and Utilization Management Programs which shall include peer reviewer, discharge planning, prior approval requirements, provider credentialing and recredentialing, medical policy development, and submission of all required HEDIS data via claims data encounter and/or clinical data systems as more fully described in the Administrative Guidelines and Provider Manual.

  • Protocols may include, but are not limited to, credential verification, Utilization Management Programs, Quality Management Programs, Enrollee Grievance Programs, or other similar programs or procedures.

  • Provider acknowledges that PLAN shall have the right to immediately withdraw Members from assignment to Provider or any of its Subcontractors in the event the health or safety of Members is jeopardized by the actions of Provider or such Subcontractor or by reason of Provider’s or such Subcontractor’s failure to provide Services in accordance with PLAN’s Quality Improvement and Utilization Management Programs (“QI/UM”) Program.

  • This component requires that Client elect a standard Utilization Management Programs promoted by Administrator.

  • Plan determines in good faith that, after notice from Plan and opportunity to cure to BJC Provider and after consultation with BJC, the BJC Provider has not materially complied with the provisions of Plan's or BJC's Quality Improvement or Utilization Management Programs or the BJC Provider is unwilling or unable to work cooperatively in a managed care environment.

  • Provider acknowledges that PARTNERSHIP shall have the right to immediately withdraw Members from assignment to Provider or any of its Subcontractors in the event the health or safety of Members is jeopardized by the actions of Provider or such Subcontractor or by reason of Provider’s or such Subcontractor’s failure to provide Services in accordance with PARTNERSHIP’s Quality Improvement and Utilization Management Programs (“QI/UM”) Program.

Related to Utilization Management Programs

  • Utilization management section means “you or your authorized representative.” Your representative will also receive all notices and benefit determinations.

  • Virginia Stormwater Management Program or “VSMP” means a program approved by the State Board after September 13, 2011, that has been established by a locality to manage the quality and quantity of runoff resulting from land-disturbing activities and shall include such items as local ordinances, rules, permit requirements, annual standards and specifications, policies and guidelines, technical materials, and requirements for plan review, inspection, enforcement, where authorized in this article, and evaluation consistent with the requirements of this article and associated regulations.

  • Medical Reimbursement Programs means a collective reference to the Medicare, Medicaid and TRICARE programs and any other health care program operated by or financed in whole or in part by any foreign or domestic federal, state or local government and any other non-government funded third party payor programs.

  • Project Management Plan means the portion of the Project Development Plan providing the information requested in Section 4.2 of Exhibit B to the ITP.

  • Prescription monitoring program or "PMP" means the Wash- ington state prescription monitoring program authorized under chapter