Managed Care Program Services Sample Clauses
The "Managed Care Program Services" clause defines the responsibilities and scope of services provided by a party in administering or supporting a managed care program. Typically, this clause outlines the specific healthcare management activities, such as coordinating patient care, processing claims, or ensuring provider network adequacy, that the service provider must perform. By clearly delineating these obligations, the clause ensures that both parties understand the expectations and standards for managed care delivery, thereby reducing misunderstandings and promoting efficient program administration.
Managed Care Program Services. Consistent with the requirements of State and Federal Law and the standards of Accreditation Organizations, PacifiCare shall be accountable for the performance of the following services for all Managed Care Plans: (i) quality management and improvement, (ii) utilization management, (iii) credentialing, (iv) Member rights and responsibilities, (v) preventive health services, (vi) medical record review and (vii) payment and processing of claims (collectively, “Managed Care Program Services”). Medical Group and its Participating Providers shall cooperate with PacifiCare in the performance of all Managed Care Program Services and conduct their activities in a manner consistent with the provisions of this Article 4 including specifically, but without limitation, PacifiCare’s QI Program, UM Program, Credentialing Program, Member Services activities, and Claims Processing Guidelines.
Managed Care Program Services. 4.1 MANAGED CARE PROGRAM SERVICES. Health Plan shall be accountable for the performance of the following services for all Managed Care Plans: (I) quality management and improvement, (ii) utilization management, (iii) credentialing, (iv) member rights and responsibilities, (v) preventive health services, (vi) medical record review and (vii) payment and processing of claims (collectively, "Managed Care Program Services"). Medical Group and its Participating Providers shall participate, cooperate and comply with Health Plan in the performance of all Managed Care Program Services. Specific activities related to utilization management, credentialing and claims processing may be delegated by Health Plan to Medical Group at such time as Medical Group demonstrates to Health Plan's satisfaction the ability to perform these functions in compliance with Health Plan's standards, as amended from time to time. Before the performance of any activities is delegated to Medical Group, Health Plan shall conduct a comprehensive audit of Medical Group's ability and administrative capacity to perform such activities. Medical Group shall provide all documentation requested by Health Plan and shall provide Health Plan representatives with on-site access to Medical Group's facilities and personnel for purposes of conducting such audit.
Managed Care Program Services. PacifiCare shall be accountable for the performance of the following services for all Managed Care Plans: (i) quality management and improvement, (ii) utilization management, (iii) credentialing, (iv) member rights and responsibilities, (v) preventive health services, (vi) medical record review and (vii) payment and processing of claims (collectively, "Managed Care Program Services"). Medical Group and its Participating Providers shall participate, cooperate and comply with PacifiCare in the performance of all Managed Care Program Services. Specific activities related to utilization management, credentialing and claims processing may be delegated by PacifiCare to Medical Group in accordance with the provisions of this Article 4. Before the performance of any activities is delegated to Medical Group, PacifiCare shall conduct a comprehensive audit of Medical Group's ability and administrative capacity to perform such activities. Medical Group shall provide all reasonable documentation requested by PacifiCare and shall provide PacifiCare representatives with on-site access to Medical Group's facilities and personnel for purposes of conducting such audit.
Managed Care Program Services. Provider agrees to abide by the Health Plan’s or Payor’s policies and procedures pertaining to the administration of Health Benefit Program services and to abide by all Provider Manuals issued by the Health Plan or Payor. The applicable policies and procedures may include, but not be limited to, policies and procedures pertaining to the Health Plan’s or Payor’s Utilization Management (“UM”) Program, Quality Management (“QM”) Program, Credentialing Program, and Claims Processing Guidelines. Such policies and procedures will outline the non-delegated requirements for claims submission, subcontract rate information, utilization management, and credentialing.
Managed Care Program Services. Consistent with the requirements of state and federal law and the standards of accreditation organization, Health Plan or the Payor shall be accountable for the performance of the following services for all Health Benefit Programs:
i. quality management and improvement, ii. utilization management, iii. credentialing,
Managed Care Program Services