Utilization Management. Contractor shall maintain a utilization management program that complies with applicable laws, rules and regulations, including Health and Safety Code § 1367.01 and other requirements established by the applicable State Regulators responsible for oversight of Contractor.
Utilization Management. Case management means a care management plan developed for a Member whose diagnosis requires timely coordination. All benefits, including travel and lodging, are limited to Covered Services that are Medically Necessary and set forth in the EOC. KFHPWA may review a Member's medical records for the purpose of verifying delivery and coverage of services and items. Based on a prospective, concurrent or retrospective review, KFHPWA may deny coverage if, in its determination, such services are not Medically Necessary. Such determination shall be based on established clinical criteria and may require Preauthorization. KFHPWA will not deny coverage retroactively for services with Preauthorization and which have already been provided to the Member except in the case of an intentional misrepresentation of a material fact by the patient, Member, or provider of services, or if coverage was obtained based on inaccurate, false, or misleading information provided on the enrollment application, or for nonpayment of premiums.
Utilization Management. All benefits are limited to Covered Services that are Medically Necessary and set forth in the Agreement. KFHPWA may review a Member's medical records for the purpose of verifying delivery and coverage of services and items. Based on a prospective, concurrent or retrospective review, KFHPWA may deny coverage if, in its determination, such services are not Medically Necessary. Such determination shall be based on established clinical criteria. KFHPWA will not deny coverage retroactively for services with Preauthorization and which have already been provided to the Member except in the case of an intentional misrepresentation of a material fact by the patient, Member, or provider of services, or if coverage under this Agreement was obtained based on inaccurate, false, or misleading information provided on the enrollment application; or for nonpayment of premiums.
Utilization Management. The HMO must have a written utilization management (UM) program description, which includes, at a minimum:
Utilization Management. The MCO must have a written utilization management (UM) program description, which includes, at a minimum:
Utilization Management. A. The Contractor shall operate a Utilization Management Program that is responsible for assuring that beneficiaries have appropriate access to specialty mental health services as required in California Code of Regulations, title 9, section 1810.440(b)(1)-(3).
Utilization Management. The Contractor shall maintain a utilization management plan and procedures consistent with the following: Staffing of all Utilization Management activities shall include, but not be limited to, a medical director, or medical director’s designee. The Contractor shall also have a medical director’s designee for behavioral health Utilization Management. The Contractor’s accountable designee(s) and staff conducting Utilization Management activities applied to the One Care Plan shall be credentialed in Massachusetts, and shall be familiar with the Massachusetts delivery system, the standards and practices of care in Massachusetts, and best practices for service delivery, and shall be accountable to the One Care Plan’s local management team in Massachusetts. Such accountable designee for Utilization Management shall participate in the One Care Plan’s Consumer Advisory Committee. All of the Contractor’s Utilization Management team members, including the accountable designees, shall: Be in compliance with all federal, State, and local professional licensing requirements; Include representatives from appropriate specialty areas. Such specialty areas shall include, at a minimum, cardiology, epidemiology, OB/GYN, psychiatry, and substance use disorders; Have at least two (2) or more years of experience in managed care or peer review activities, or both; Not have had any disciplinary actions or other type of sanction ever taken against them, in any state or territory, by the relevant professional licensing or oversight board or the Medicare and Medicaid programs; and Not have any sanctions relating to his or her professional practice including, but not limited to, malpractice actions resulting in entry of judgment against him or her, unless otherwise agreed to by EOHHS; In addition to the requirements set forth in Section 2.9.4.4, the medical director’s designee for Behavioral Health utilization management shall also: Be board‑certified or board‑eligible in psychiatry; and Be available twenty‑four (24) hours per day, seven days a week for consultation and decision‑making with the Contractor’s clinical staff and providers. The Contractor shall have in place policies and procedures that at a minimum: Routinely assess the effectiveness and the efficiency of the utilization management program; Evaluate the appropriate use of medical technologies, including medical procedures, diagnostic procedures and technology, Behavioral Health treatments, pharmacy formularies and devi...
Utilization Management. State law requires that health plans disclose to Members and health plan providers the process used to authorize or deny health care services under the plan. Blue Shield has completed documentation of this process as required under Section 1363.5 of the California Health and Safety Code. The document describing Blue Shield’s Utilization Management Program is available online at xxx.xxxxxxxxxxxx.xxx or Members may call the Customer Service Department at the number provided on the back page of this Evidence of Coverage to request a copy.
Utilization Management. 2.1 The contractor shall establish a Medical Management (MM)/UM Plan for care received by TRICARE beneficiaries.
Utilization Management. The process of evaluating the necessity, appropriateness and efficiency of health care services against established guidelines and criteria.
