Managed Care Process Clause Samples

The Managed Care Process clause outlines the procedures and requirements for coordinating and overseeing healthcare services within a managed care framework. Typically, this clause details how providers must obtain pre-authorization for certain treatments, adhere to utilization review protocols, and follow specific reporting or documentation standards. Its core function is to ensure that healthcare services are delivered efficiently and cost-effectively, while maintaining quality standards and controlling unnecessary expenditures.
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. Following review, HPN will complete the Prior Authorization written notification 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 Appeals Procedures Section).
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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).
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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.
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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:
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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.
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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).
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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).
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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.
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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.
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Related to Managed Care Process

  • Complaints Process The School shall establish and adhere to a process for resolving public complaints which shall include an opportunity for complainants to be heard. The final administrative appeal shall be heard by the School's Governing Board, except where the complaint pertains to a possible violation of any law or term under this Contract. The complaints process shall be readily accessible from the School’s website, as described in Section 11.4.1.

  • CENTRAL GRIEVANCE PROCESS The following process pertains exclusively to grievances on central matters that have been referred to the central process. In accordance with the School Boards Collective Bargaining Act central matters may also be grieved locally, in which case local grievance processes will apply.

  • Grievance Process (a) Either party, with the agreement of the other party, may submit a grievance to Grievance Mediation at any time within ten (10) working days after the Employer’s decision has been rendered at the step prior to arbitration. Where the matter is so referred, the mediation process shall take place before the matter is referred to Arbitrator. (b) Grievance Mediation shall be scheduled within twenty (20) working days of the grievance being submitted to mediation, or longer period as agreed by the parties. (c) No matter may be submitted to Grievance Mediation which has not been properly carried through the grievance procedure, provided that the parties may extend the time limits fixed in the grievance procedure. (d) The parties shall agree on a mediator. (e) Proceedings before the Mediator shall be informal. Accordingly, the rules of evidence will not apply, no record of the proceedings shall be made and legal counsel shall not be used by either party, unless otherwise mutually agreed. (f) If possible, an agreed statement of facts will be provided to the Mediator, and if possible, in advance of the Grievance Mediation Conference. (g) The Mediator will have the authority to meet separately with either party. (h) If no settlement is reached within five (5) working days following Grievance Mediation, the parties are free to submit the matter to Arbitration in accordance with the provisions of the collective agreement. In the event that a grievance which has been mediated subsequently proceeds to arbitration, no person serving as the Mediator may serve as an Arbitrator, unless otherwise mutually agreed. Nothing said or done by the mediator may be referred to Arbitration. (i) The Union and Employer will share the cost of the Mediator, if any.

  • Grievance Processing Union stewards or Union officials shall be permitted to have time off without loss of pay for the investigation and processing of grievances and arbitrations. Requests for such time off shall be made in advance and shall not be unreasonably denied. The Union will furnish the Employer with a list of Union stewards and their jurisdictions. The Union shall delineate the jurisdiction of Union stewards so that no ▇▇▇▇▇▇▇ need travel between work locations or sub-divisions thereof while investigating grievances. Grievants shall be permitted to have time off without loss of pay for processing their grievances through the contractual grievance procedure, except that for class action grievances no more than three (3) grievants shall be granted such leave.

  • Selection Process The Mortgage Loans were selected from among the outstanding one- to four-family mortgage loans in the Seller's portfolio at the related Closing Date as to which the representations and warranties set forth in Subsection 9.02 could be made and such selection was not made in a manner so as to affect adversely the interests of the Purchaser;