Managed Care Process Clause Samples

Managed Care Process. The Medical Director and/or SHL's Utilization Review Committee will review proposed services and supplies to be received by an Insured to determine:  If the services are Medically Necessary and/or appropriate.  The appropriateness of the proposed setting.  The required duration of treatment or admission. Following review, SHL will complete the Prior Authorization written notification and send a copy to the Provider and the Insured. This form will specify approved services and supplies. Prior Authorization is not a guarantee of payment for Covered Services. The final decision as to whether any care should be received is between the Insured and the Provider. If SHL denies a request by an Insured and/or Provider for Prior Authorization of a service, the Insured or his Authorized Representative may appeal the denial to the Grievance Review Committee (see the Appeals Procedures Section).

Managed Care Process. The Medical Director and/or SHL's Utilization Review Committee will review proposed services and supplies to be received by an Insured to determine:  If the services are Medically Necessary and/or appropriate.  The appropriateness of the proposed setting.  The required duration of treatment or admission.

Managed Care Process. This section tells you about HPN’s Managed Care Program and which Covered Services require Prior Authorization. HPN's Managed Care Program, using the services of professional medical peer review committees, utilization review committees, and/or the Medical Director, determines whether services and supplies are Medically Necessary. HPN’s Managed Care Program helps direct the patient to the most appropriate setting to provide healthcare in a cost-effective manner. HPN's Managed Care Program requires the Member, Plan Providers and HPN to work together.  All Plan Providers have agreed to participate in HPN’s Managed Care Program. Plan Providers have agreed to accept HPN’s Reimbursement Schedule amount as payment in full for Covered Services, less the Member’s payment of any applicable Copayment, Deductible or Coinsurance amount, whereas Non-Plan Providers have not. Members enrolled under HPN’s HMO Plans who use the services of Non-Plan Providers will receive no benefit payments or reimbursement for amounts for any Covered Service, except in the case of Emergency Services or Urgently Needed Services as defined in this AOC, or other Covered Services provided by a Non-Plan Provider that are Prior Authorized by HPN’s Managed Care Program including any Prior Authorized Covered Services obtained from a Non-Plan outpatient facility, such as a laboratory, radiological facility (x-ray), or any The Medical Director and/or HPN's Utilization Review Committee will review proposed services and supplies to be received by a Member to determine:

Managed Care Process.  It is the Insured's responsibility to verify Prior Authorization has been obtained for any Covered Services requiring Prior Authorization and to comply with all other rules of SHL’s Managed Care Program. The Medical Director and/or SHL's Utilization Review Committee will review proposed services and supplies to be received by an Insured to determine:  If the services are Medically Necessary and/or appropriate.  The appropriateness of the proposed setting.  The required duration of treatment or admission.

Managed Care Process.  Compliance by the Member with HPN’s Managed Care Program is mandatory. Failure by the Member to comply with the rules of HPN’s Managed Care Program means the Member will be responsible for costs of services received. The Medical Director and/or HPN's Utilization Review Committee will review proposed services and supplies to be received by a Member to determine:  If the services are Medically Necessary and/or appropriate.  The appropriateness of the proposed setting.  The required duration of treatment or admission. Following review, HPN will complete the Prior Authorization form and send a copy to the Provider and the Member. The form will specify approved services and supplies. Prior Authorization is not a guarantee of payment. The final decision as to whether any care should be received is between the Member and the Provider. If HPN denies a request by a Member and/or Provider for Prior Authorization of a service or supply, the Member or Provider may appeal the denial to the Grievance Review Committee (see Section 10, Appeals Procedures).

Managed Care Process. The Dental Director and/or SHL's Utilization Review Committee will review proposed services and supplies to be received by an Insured to determine: • If the services are Medically Necessary and/or appropriate. • The appropriateness of the proposed setting. • The required duration of treatment or admission. The final decision as to whether any care should be received is between the Insured and the Provider. If SHL denies a request by an Insured and/or Provider, the Insured or his Authorized Representative may appeal the denial to the Grievance Review Committee (see the Appeals Procedures Section).

Managed Care Process. All emergency admissions are reviewed Retrospectively to determine if the treatment received was Medically Necessary and appropriate and was for Emergency Services as defined in this AOC. If such Emergency Services are provided by Non-Plan Providers, all Medically Necessary professional, Inpatient or outpatient Emergency Services will be Covered Services.

Managed Care Process. The Medical Director and/or HPN's Utilization Review Committee will review proposed services and supplies to be received by a Member to determine:  If the services are Medically Necessary and/or appropriate.  The appropriateness of the proposed setting.  The required duration of treatment or admission.