Quality; Utilization Management. Pursuant to any applicable provider manuals and related protocols, or as elsewhere specified under the Agreement, Provider agrees to cooperate with Subcontractor’s and Health Plan’s quality assessment, performance improvement and utilization review and management activities. This shall include, but not be limited to, participation in any internal and external quality assurance, utilization review, peer review, and grievance procedures established by Subcontractor or Health Plan or as required under the State Contract to ensure that Covered Persons have due process for their complaints, grievances, appeals, fair hearings or requests for external review of adverse decisions made by Subcontractor, Health Plan or Provider. Provider shall adhere to the quality assurance and utilization review standards of the applicable State Program and shall monitor quality and initiate corrective action to improve quality consistent with the generally accepted level of care.
Quality; Utilization Management. Pursuant to any applicable provider manuals and related protocols, or as elsewhere specified under the Agreement, Provider agrees to cooperate with United’s quality improvement and utilization review and management activities. This shall include, but not be limited to, participation in any internal and external quality assurance, utilization review, peer review, and grievance procedures established by United or as required under the State Contract to ensure that Covered Persons have due process for their complaints, grievances, appeals, fair hearings or requests for external review of adverse decisions made by United or Provider. Provider shall adhere to the quality assurance and utilization review standards of the State Program and shall monitor quality and initiate corrective action to improve quality consistent with the generally accepted level of care.
Quality; Utilization Management. Provider agrees to participate and cooperate with any quality improvement, utilization review, and management activities established by Subcontractor, Health Plan and/or the Division of TennCare, including actions to improve patient safety and quality. This shall include, but not be limited to, participation in any internal and external quality assurance, utilization review, peer review, and grievance procedures established by Health Plan or as required under the applicable CRA to ensure that Covered Persons have due process for their complaints, grievances, appeals, fair hearings or requests for external review of adverse decisions made by Subcontractor, Health Plan or Provider.
Quality; Utilization Management. Provider shall cooperate with Subcontractor and Health Plan's peer review, grievance, quality improvement program and utilization management activities, and recognizes that Health Plan or its subcontractor will provide monitoring and oversight of Provider, including monitoring of services rendered to Covered Persons as agreed upon between Subcontractor, Health Plan and Provider based on services provided. If Health Plan has delegated credentialing to Provider, Provider shall ensure that all licensed medical professionals are credentialed in accordance with Health Plan’s and the Agency’s credentialing requirements as set forth in the State Contract.
Quality; Utilization Management. Pursuant to any applicable provider manuals and related protocols, or as elsewhere specified under the Agreement, Provider agrees to cooperate with Subcontractor’s and Health Plan’s quality assessment, performance improvement and utilization review and management activities, which shall be tailored to the nature and type of services subcontracted. This shall include, but not be limited to, participation in any internal and external quality assurance, utilization review, peer review, and grievance procedures established by Subcontractor or Health Plan or as required under the applicable State Contract to ensure quality control for the health care provided, including but not limited to the accessibility of Medically Necessary health care, and Covered Persons have due process for their complaints, grievances, appeals, fair hearings or requests for external review of adverse decisions made by Subcontractor, Health Plan or Provider. Provider shall adhere to the quality assurance and utilization review standards of the State Programs and shall monitor quality and initiate corrective action to improve quality consistent with the generally accepted level of care. Provider is not required to indemnify Subcontractor or Health Plan for any expenses or liabilities incurred in connection with any claim or action brought against Subcontractor or Health Plan based on Subcontractor’s or Health Plan’s management decisions, utilization review provisions or other policies, guidelines or actions except, to the extent, such claim or action is as a result of Provider’s fault or negligence.
Quality; Utilization Management. Provider agrees to cooperate with Subcontractor’s quality improvement and utilization review and management activities. This shall include, but not be limited to, participation in any internal and external quality assurance, utilization review, peer review, and grievance procedures established by Subcontractor or as required under the State Contract to ensure that Customers have due process for their complaints, grievances, appeals, fair hearings or requests for external review of adverse decisions made by Subcontractor or Provider. Provider shall adhere to the quality assurance and utilization review standards of the State Program and shall monitor quality and initiate corrective action to improve quality consistent with the generally accepted level of care.
Quality; Utilization Management. Pursuant to any applicable provider manuals and related protocols, or as elsewhere specified under the Agreement, Provider agrees to cooperate with Subcontractor and Health Plan’s quality improvement and utilization review and management activities. This shall include, but not be limited to, participation in any internal and external quality assurance, utilization review, peer review, and grievance procedures established by Subcontractor and Health Plan or as required under the State Contract to ensure that Covered Persons have due process for their complaints, grievances, appeals, fair hearings or requests for external review of adverse decisions made by United or Provider. Provider shall adhere to the quality assurance and utilization review standards of the MississippiCAN Program and shall monitor quality and initiate corrective action to improve quality consistent with the generally accepted level of care.
Quality; Utilization Management. Provider shall cooperate with and abide by Health Plan’s quality management program, which includes Health Plan’s quality assurance and utilization review policies and procedures, and the quality management/utilization management program requirements set forth in the applicable State Contract. In addition, hospital Providers participating in the Medical Assistance Program must comply with the following utilization management requirements related to inpatient hospital stays: The Medical Assistance State Contract requires Health Plan’s utilization management program to monitor the progress of a Covered Person’s inpatient hospital stay through receipt of appropriate clinical information from the hospital within two (2) business days from the time of admission that details a Covered Person’s admission information, progress to date, and any additional pertinent data. Hospital Providers shall agree to Health Plan’s and/or Subcontractor’s monitoring of the appropriateness of a continued inpatient stay beyond approved days according to established criteria under the direction of Health Plan’s medical director and shall provide Health Plan and/or Subcontractor all necessary clinical information in a timely manner to allow for appropriate decision-making and management of care.
Quality; Utilization Management. Provider agrees to participate and cooperate with any quality improvement, utilization review, and management activities established by United and/or the Division of TennCare, including actions to improve patient safety and quality. This shall include, but not be limited to, participation in any internal and external quality assurance, utilization review, peer review, and grievance procedures established by United or as required under the applicable CRA to ensure that Covered Persons have due process for their complaints, grievances, appeals, fair hearings or requests for external review of adverse decisions made by United or Provider.
Quality; Utilization Management. Pursuant to any applicable provider manuals and related protocols, or as elsewhere specified under the Agreement, Provider agrees to cooperate with Health Plan’s and Subcontractor’s quality assessment, performance improvement and utilization review and management activities. This shall include, but not be limited to, participation in any internal and external quality assurance, utilization review, peer review, and grievance procedures established by Health Plan and Subcontractor or as required under the Centennial Care Contract to ensure that Covered Persons have due process for their complaints, grievances, appeals, fair hearings or requests for external review of adverse decisions made by Health Plan and/or Subcontractor or Provider. Provider shall adhere to the quality assurance and utilization review standards of the applicable Centennial Care Program and shall monitor quality and initiate corrective action to improve quality consistent with the generally accepted level of care. Furthermore, Provider agrees to participate and cooperate in any internal and external QM/QI monitoring, utilization review, peer review and/or Appeal procedures established by Health Plan, Subcontractor, and/or State.
