Medical Management. The benefits available to You under this Contract may be subject to pre-service, concurrent and retrospective reviews to determine when services should be covered by Us. The purpose of these reviews is to promote the delivery of cost-effective medical care by reviewing the use of procedures and, where appropriate, the setting or place the services are performed. Covered Services must be Medically Necessary for benefits to be provided.
Medical Management. The process of properly allocating healthcare resources through programs such as Utilization Management and Case Management.
Medical Management. PHS shall be solely responsible for all claims processing and auditing, health services (including hospital pre-certification, outpatient pre-certification, large claim case management and utilization review) and all risk accounting for the provider bonus arrangements under the HMO Plans.
Medical Management. The benefits available to You under this Policy may be subject to pre-service, concurrent and retrospective reviews to determine when services should be Covered by Us. The purpose of these reviews is to promote the delivery of cost-effective dental care by reviewing the use of procedures and, where appropriate, the setting or place the service are performed. Covered Services must be Medically Necessary for benefits to be provided.
Medical Management. (1) State Fund will utilize available medical networks to ensure maximum medical cost containment.
Medical Management. The MCO shall provide medical management services for all workers' compensation cases that result from injuries and occupational diseases to employees arising out of the course and scope of employment as provided by law, including Medical Case Management services as defined under Appendix G of this Agreement). The MCO recognizes that (1) all services provided are linked to the successful return to work or resolution for injured workers, (2) close interaction between the MCO and the employer is critical to the program's success, (3) close attention to treatment protocols and Treatment Plans is required, (4) provider networks must emphasize the appropriate provider composition to treat occupational injuries and illness, and (5) continually meeting data requirements is essential for effecting and measuring return to work.
Medical Management. The Contractor shall identify any requested medical services related to motor vehicle accidents, or work related injuries, and refer these claims to the recoveries specialist for further investigation.
Medical Management. Given the short duration (3 months) of the contract period, it is unlikely that significant medical management improvements can be achieved. Therefore, we did not assume any savings due to medical management for Physical Health. (AA3.11) Mi Salud Changes There were no programmatic changes . Several programmatic changes became effective October 1, 2011. We chose the base period to reflect the experience of the Mi Salud program after these changes were in effect. Administrative Fees and Risk Margin The rating methodology includes an explicit provision for administrative services . The amount allocated adminis'ra'i'e expenses is 5.5% of PIUS.1.0% risk margin. Certified Rates Attachment 1 to this report provides a buildup of the calculation of the certified Physical Health Rates by Region . These rates are only appropriate for the July 1, 2011 to September 30, 2011. I •• , t ;. i " ' I J ' Offices in Principal Cities Worldwide Attachment 1 Development of Actuarially Certified Rates Physical Health 10 - =July 1, 2115 /2011 $66.36 SouthEast $60.69 Southwest $53.25 2.50% 2.500/. 2.50% . 0% 0% 0% $76.11 $6797 $59.79, $17.22 $15.43 $17.14 1.000 1.000 1.000 1.000 $15.43 $17. 14 9.9% 7.0% 7 .9% 3.5% 3.5% $19.19 $18.36: $16.24 $18.1 2 0.998 0 .999 $3.62 $3. 95 1.0%' 1.0% · 1.0% 2.0% 2.0%" 2.0% 7.0% 7.0% $4.67 $4.1 1 $4.29 $14.08 $18. 99
Medical Management. Medical Case Management is a collaborative process that facilitates recommended treatment plans to assure the appropriate medical care is provided to Medicaid members. It refers to the planning and coordination of health care services appropriate to achieve the goal of medical rehabilitation. Medical Necessity – Medically Necessary Services are those services utilized in the State Medicaid Program, including quantitative and non-quantitative treatment limits, as indicated in State statutes and regulations, the State Plan, and other State policy and Procedures. Medicare – A federal health insurance program for people 65 or older and certain individuals with disabilities. Member Incentive – Incentives to encourage a Medicaid Managed Care Member to change or modify behaviors or meet certain goals. Member or Medicaid Managed Care Member – An eligible person who is currently enrolled with a Department approved Medicaid Managed Care CONTRACTOR. Throughout this contract, this term is used interchangeably with “Enrollee” and “Beneficiary”. Minimum Performance Standards (MPS) – The CONTRACTOR is expected to meet a minimum level of performance as identified in the Managed Care Policy and Procedure Guide—a specific list of Quality metrics (aka the withhold metrics). These minimum levels of performance are referred to as the Minimum Performance Standards (MPS). Minimum Subcontract Provision (MSP) – Specific contractual requirements the CONTRACTOR must include in Subcontracts. Moderate-Risk Member – The Moderate-Risk Members do not meet Low- or High-Risk criteria. National Committee for Quality Assurance (NCQA) – A private, 501(c)(3) non-for-profit organization founded in 1990, and dedicated to improving health care Quality. National Drug Code (NDC) – A unique 10-digit, 3-segment numeric identifier assigned to each medication listed under Section 510 of the US Federal Food, Drug, and Cosmetic Act. The segments identify the labeler or vendor, product (within the scope of the labeler), and trade package (of this product).
Medical Management. 1. Describe how your company will meet the requirements outlined in 2.18 Medical Management.
