Utilization Management Program means a program approved by BLUE CROSS and designed to review and manage the utilization of Covered Medical Services.
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.
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 guide- lines. 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.
Examples of Utilization Management Program in a sentence
The UM Director is responsible for overseeing the day-to-day operational activities of the Utilization Management Program in accordance with state guidelines.
This program should have a Dental Utilization Management Program description, work plan, an implementation mechanism, policies and procedures and program evaluation with evaluative criteria, all of which shall be reviewed and updated annually.
The Dental Utilization Management Program must include: • Prior authorization; • Profiling of primary care dentists and analysis of utilization data to detect underutilization and overutilization of services; • Investigation and intervention, as appropriate, when utilization and/or quality of care issues are identified; and • Direction and analysis of periodic reviews of members’ service utilization patterns.
OHCA reserves the right to review and approve the Contractor’s Dental Utilization Management Program description, work plan, policies and procedures and program evaluation with evaluative criteria during Readiness Review, annually and at times specified by OHCA.
More Definitions of Utilization Management Program
Utilization Management Program means a comprehensive approach and planned activities for evaluating the appropriateness, need, and efficiency of services, procedures, and facilities according to established criteria or guidelines. Utilization management typically includes new activities or decisions based upon the analysis of care, and describes proactive procedures, including discharge planning, concurrent planning, precertification, and clinical case Appeals. It also covers proactive processes, such as concurrent clinical reviews and Peer Reviews, as well as Appeals introduced by the Provider, payer, or Enrollee.
Utilization Management Program means a comprehensive approach and planned activities for evaluating the appropriateness, need, and efficiency of services, procedures, and facilities according to established criteria orguidelines. Utilization management typically includes new activities or decisions based upon the analysis of care, and describes proactive procedures, including discharge planning, concurrent planning, precertification, and clinical case Appeals. It also covers proactive processes, such as concurrent clinical reviews and Peer Reviews, as well as Appeals introduced by the Provider, payer, or Enrollee.
Utilization Management Program means the infrastructure required to carry out the 25 concurrent review services according to this Contract including, but not limited to, policies and 26 procedures, request staffing and information systems.
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 (i) the utilization management program developed, established and administered by IPA 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 IPA, or (iii) a utilization management program developed, established and administered by a Payor.
Utilization Management Program means the program approved by IPA and designed to review and manage the appropriate utilization of Covered Health Care Services provided to Plan Members. A summary of the Utilization Management Program is included in Attachment A.
Utilization Management Program means those procedures adopted by AvMed to assure that the supplies and services provided to Participants are Medically Necessary. These include, but are not limited to: (1) pre-authorization for all inpatient services, observation services, residential treatment, outpatient surgery, intensive outpatient programs, complex radiological imaging (CT, MRI, MRA, PET and Nuclear Cardiac Imaging), non-emergency ambulance, dialysis services, transplant services, use of Non-Participating Provider, select medications including injectables;(2) concurrent review of all patients hospitalized in acute care, psychiatric, rehabilitation, andSkilled Nursing Facilities, including on-site review when appropriate; (3) case management for all inpatients who need continued care in an alternative setting (such as homecare or a Skilled Nursing Facility) and for outpatients when deemed appropriate. The program may also advocate alternative cost-effective settings for the delivery of prescribed care and may identify other options for non-covered health care needs.