Common use of Care Coordinators Clause in Contracts

Care Coordinators. The Plan shall utilize licensed personnel in medical professions to review requests for Prior Authorization and perform the duties of Care Coordinators. Such Care Coordinators shall have authority to perform Utilization Review per established scientific, evidence-based clinical criteria for the purpose of making a determination as to the Medical Necessity for services under the terms and provisions of the Member's Benefit Agreement. Utilization Review Criteria shall be based on currently established and recognized medical and professional expertise, studies, treatises and literature, and current cumulative information, data and studies on health care services available and provided within the local community.

Care Coordinators. The Plan shall utilize licensed personnel in medical professions to review requests for Prior Authorization and perform the duties of Care Coordinators. Such Care Coordinators shall have authority to perform Utilization Review per established scientific, evidence-evidence- based clinical criteria for the purpose of making a determination as to the Medical Necessity for services under the terms and provisions of the Member's ’s Benefit Agreement. Utilization Review Criteria shall be based on currently established and recognized medical and professional expertise, studies, treatises and literature, and current cumulative information, data and studies on health care services available and provided within the local community.