Adherence to BCBSM Quality and Utilization Management Policies Clause Samples
The "Adherence to BCBSM Quality and Utilization Management Policies" clause requires parties to comply with the quality and utilization management standards set by Blue Cross Blue Shield of Michigan (BCBSM). In practice, this means that providers or contractors must follow specific protocols for patient care, reporting, and resource use as outlined by BCBSM, such as adhering to guidelines for medical necessity reviews or participating in quality improvement initiatives. The core function of this clause is to ensure consistent, high-quality care and efficient use of resources, while aligning provider practices with BCBSM’s established policies and expectations.
Adherence to BCBSM Quality and Utilization Management Policies. Adhere to all quality management, utilization management and reimbursement policies and procedures of BCBSM regarding precertification, case management, disease management, retrospective profiling, credentialing or privileging specific to particular procedures, billing limitations or other programs which may be in effect at the time the Covered Service is provided, and submit reports, including data, as requested by BCBSM;