Retrospective Review. A review that is conducted after services are provided to a Member.
Retrospective Review. Within thirty (30) calendar days in accordance with Health and Safety Code Section 1367.01, or any future amendments thereto.
Retrospective Review. The INSURER will establish a Retrospective review Program that will address quality and utilization problems that may arise, as described in the INSURER's Proposal. The INSURER shall notify the ADMINISTRATION on a quarterly basis of all findings in the Retrospective Review Program. The ADMINISTRATION may review and/or audit the program findings at any time.
Retrospective Review. The INSURER will establish a program to determine medical necessity and service adequacy after the service has been rendered or paid to providers or physicians.
Retrospective Review. When a FCOI is not identified or managed in a timely manner or when an Investigator fails to comply with a management plan, the DIO, within 120 days of a determination of non- compliance, must complete a retrospective review of the Investigator’s activities and the PHS Award to determine if there was bias in the design, conduct, or reporting of such research. The information that must be documented in the retrospective review is outlined in Appendix C. If bias is found through a retrospective review, the DIO will notify the PHS Awarding Component promptly and submit a mitigation report containing the information outlined in Appendix D. Thereafter, the DIO will submit FCOI reports annually as described in Appendix A.
Retrospective Review. For projects that have not yet proceeded to construction, site-specific cultural resource investigations, surveys and reports used to support the Section 106 review process that are five or more years old will be re-evaluated by WSDOT. The purpose of this re-evaluation is to establish whether, with the benefit of additional information gathered in the undertaking or otherwise over the passage of time, such materials accurately and correctly characterize the sites under review. This re-evaluation includes the undertaking in its final design, the Area of Potential Effects, and all historic properties present within the APE. Depending upon the results of the re-evaluations conducted pursuant to this paragraph, the re-evaluation may be submitted to FHWA for concurrence and SHPO for comment and shall be made available to the public upon request.
Retrospective Review. If a health care service has been pre-authorized or approved, the specific standards, criteria or procedures used in the determination shall not be modified pursuant to retrospective review.
Retrospective Review. Within thirty (30) calendar days in accordance with Health and Safety Code Section 1367.01, or any future amendments thereto. Retrospective review applies only to Medi-Cal services, but Contractor may at its discretion apply retrospective review to Medicare services.
Retrospective Review. The Contractor shall develop retrospective review policies and procedures as part of its Dental Management Program. The retrospective review component of the Dental Management Program shall evaluate the appropriateness of care previously received by a Dental Health Plan Enrollee. The Contractor shall ensure the retrospective review process evaluates suspended claims within 14 days or sooner, if feasible, and shall deliver the decision on coverage to the Provider no later than the next Business Day after a decision is reached. Authorization Denials and Peer-to-Peer Review In accordance with 42 C.F.R. § 438.210(b)(3), any decision to deny a Service Authorization request or to authorize a service in an amount, duration, or scope that is less than requested shall be made by an individual who has appropriate expertise in addressing the Dental Health Plan Enrollee’s oral health needs. The Contractor shall permit Providers to request a peer-to-peer review process for all Service Authorization denials or authorizations in an amount, duration, or scope less than requested. Direct Access to Specialists In accordance with 42 C.F.R. § 438.208(c)(4), for Dental Health Plan Enrollees with Special Health Care Needs determined through a comprehensive assessment to need a course of treatment or regular care monitoring, the Contractor shall have a mechanism in place to allow Dental Health Plan Enrollees to directly access a specialist as appropriate for the Dental Health Plan Enrollee’s condition and identified needs.
Retrospective Review. If a patient or provider fails to contact the UM Vendor prior to an elective hospital admission or within forty-eight (48) hours of an emergency admission, the UM Vendor will conduct a retrospective review for medical necessity. A pre-certification record will be created and transmitted to the Plan’s TPA upon completion of the review. Retrospective reviews may also be required to resolve Medicare Secondary Payment demands. Continued Stay Management Prior to an expected discharge date, the UM Vendor is required to contact the attending physician or facility for an update on the patient’s progress, treatment, and discharge plans. If the clinical data provided correspond with the appropriate medical protocols, any additional days of continued stay appropriate to the individual patient’s need are recommended, and the date for the next review is established with the attending physician or the facility. The UM Vendor will perform continued stay reviews on DRG admissions within appropriate intervals if the admission could result in the need for case management services.
