DELEGATION OF UTILIZATION REVIEW ACTIVITIES AND CRITERIA Sample Clauses

DELEGATION OF UTILIZATION REVIEW ACTIVITIES AND CRITERIA. 1. Utilization Review and Criteria for Behavioral Health Services Utilization Review activities for behavioral health services (Mental Health and Substance Use Disorder services) have been delegated by the HMO to its contracted behavioral health management company which administers the behavioral health Benefits for the majority of the HMO's Members. Members seeking Mental Health care and Substance Use Disorder services may obtain Preauthorization for such services from the contracted behavioral health management company.
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DELEGATION OF UTILIZATION REVIEW ACTIVITIES AND CRITERIA. The Carrier delegates its utilization review process to the Carrier’s affiliate, Independence Healthcare Management (“IHM”). IHM is a state licensed utilization review entity and is responsible for the Carrier’s utilization review process. In certain instances, the Carrier has delegated certain utilization review activities, including Precertification review, concurrent review, and case management, to integrated delivery systems and/or entities with an expertise in medical management of a certain membership population (such as, Neonates/premature infants) or type of benefit or service (such as mental health/substance abuse or radiology). In such instances, a formal delegation and oversight process is established in accordance with applicable law and nationally-recognized accreditation standards. In such cases, the delegate’s utilization review criteria are generally used, with the Carrier’s approval. Utilization Review and Criteria for Mental Health/Substance Abuse Services Utilization Review activities for mental health/substance abuse services have been delegated by IBC (and QCC) to a behavioral health management company, which administers the mental health and substance abuse benefits for the majority of the Carrier’s Covered Persons.
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