QUALITY AND UTILIZATION REVIEW Clause Samples

QUALITY AND UTILIZATION REVIEW. 11.1 PROVIDER agrees to participate in FIRST MEDICAL utilization review program. PROVIDER agrees to comply with FIRSR MEDICAL policies and procedures including full cooperation with the clinical review process, which includes making medical records available to FIRST MEDICAL auditors or its delegated party on a concurrent basis and to provide data requested by FIRST MEDICAL to conduct quality and utilization review activities of any additional programs developed by First Medical clinical area concerning FIRST MEDICAL Enrollees. 11.2 PROVIDER agrees to obtain from Enrollees authorization for FIRST MEDICAL review personnel to have access to Enrollees during their term of treatment and to Enrollees’ medical records, and pursuant to such authorization, provide FIRST MEDICAL review personnel such access. PROVIDER agrees to provide FIRST MEDICAL review personnel access to PROVIDER and PROVIDER’s personnel during the term of an Enrollee’s inpatient stay. 11.3 PROVIDER agrees to deliver Covered Services, which are appropriate and Medically Necessary and to document adequately in Enrollees’ paper and electronic medical records those PROVIDER Services rendered to Enrollees. PROVIDER agrees that in the event of a denial of payment for PROVIDER Services rendered to Enrollees determined not to be Medically Necessary by FIRST MEDICAL, that PROVIDER shall not bill, charge, seek payment or have any recourse against Enrollee for such services. 11.4 IMC and/or FIRST MEDICAL will appoint an administrative staff liaison to resolve operational issues in accordance with the terms of this agreement. PROVIDER agrees to allow IMC and/or FIRST MEDICAL to implement interventions that will promote communication with Enrollees, educational intervention and will facilitate process for audits (clinical and non-clinical). 11.5 PROVIDER agrees to notify and present evidence to IMC and/or FIRST MEDICAL of any professional services agreement which PROVIDER delegate to a Third Party the authority to bill.