Medical Management. The benefits available to You under this Contract are 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. 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. Attached hereto as Schedule 8.15 is a copy of the medical management and quality assurance policies and procedures that Seller uses or has used since January 1, 1997 with respect to the Acquired Business. Seller has delivered to Purchaser a true, correct and complete copy of the minutes maintained by Seller's medical management and quality assurance committees since January 1, 1998. Except as set forth in Schedule 8.15, Seller's medical management and quality assurance policies comply in all material respects with all applicable laws, rules, regulations and Commercial Contract requirements.
Medical Management. Authorizations 1. Describe the process of entering referrals. Are they entered on-line or on paper? Please have available examples of the forms used to track referral information. 2. Describe the types of service that will always require an authorization in order to be paid. 3. Describe the type of services that if unauthorized will pay a reduced benefit. 4. Describe the types of service that will be denied if unauthorized. 5. Do you automatically assign next review date for Hospital authorizations? [ ] Yes [ ] No Describe: 6. Describe reasons for pending or denying authorizations.
Medical Management. Staffing of nurse case managers, the functions of all case-based medical/functional determinations and associated activities (except for Triage & Intake services as outlined in E x h i b i t A . S e c t i o n 3 ) , Stay At Work/Return To Work program activities, and overall management of the medical management aspects of the program, including all provider training relative to CBM principles. (CSI credentials and manages the SBBC network);
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 benefits available to You under this Contract are 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. We may base Our decision on a review of: Your medical records; Our medical policies and clinical guidelines; Medical opinions of a professional society, peer review committee or other groups of Physicians; Reports in peer-reviewed medical literature; Reports and guidelines published by nationally-recognized health care organizations that include supporting scientific data; Professional standards of safety and effectiveness, which are generally- recognized in the United States for diagnosis, care, or treatment; The opinion of Health Care Professionals in the generally-recognized health specialty involved; The opinion of the attending Providers, which have credence but do not overrule contrary opinions. Services will be deemed Medically Necessary only if: They are clinically appropriate in terms of type, frequency, extent, site, and duration, and considered effective for Your illness, injury, or disease; They are required for the direct care and treatment or management of that condition; Your condition would be adversely affected if the services were not provided; They are provided in accordance with generally-accepted standards of medical practice; They are not primarily for the convenience of You, Your family, or Your Provider; They are not more costly than an alternative service or sequence of services, that is at least as likely to produce equivalent therapeutic or diagnostic results; When setting or place of service is part of the review, services that can be safely provided to You in a lower cost setting will not be Medically Necessary if they are performed in a higher cost setting. For example, We will not provide coverage for an inpatient admission for surgery if the surgery could have been performed on an outpatient basis or an infusion or injection of a specialty drug provided in the outpatient department of a Hospital if the drug could be provided in a Physician’s office or the home setting. See the Utilization Review and External Appeal sections of this Contract for Your right to an internal Appeal and e...