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. 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 220.127.116.11, 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. PacifiCare shall maintain an ongoing Utilization Management Program (“UM Program”) to address pre-authorization, concurrent and retrospective review of the quality, appropriateness, level of care and utilization of all Covered Services provided or to be provided to Members under the Managed Care Plans. The UM Program shall be maintained in accordance with the requirements of State and Federal Law and the standards of Accreditation Organizations. Medical Group shall establish and maintain a utilization review committee which shall meet as frequently as necessary. A member of the PacifiCare medical services staff may participate in Medical Group’s utilization review committee meetings. Medical Group shall keep minutes of its utilization review committee meetings, copies of which shall be made available to PacifiCare upon ten (10) days’ written notice by PacifiCare to Medical Group. Medical Group’s utilization review committee shall review, as necessary, elective referrals and hospital and skilled nursing facility admissions on a prospective basis, and Emergency Services and Urgently Needed Services requiring hospital admissions on a retrospective basis. The committee shall also be responsible for monitoring patterns of care, isolating inappropriate utilization and performing other management and review duties as specified in the UM Program.
Utilization Management. Providers shall cooperate and participate in Health Plan’s utilization review and case management programs. Health Plan’s utilization review/case management programs may include provisions for (a) verification of eligibility and prior authorization for Covered Services, (b) concurrent and retrospective reviews, (c) requirements regarding referrals to third party Participating Providers, and (d) corrective action plans.
Utilization Management. Director who is an Ohio-licensed registered nurse or a physician with a current unencumbered license through the Ohio State Medical Board. This person may have a certification as a Certified Professional in Health Care Quality (CPHQ) by the National Association for Health Care Quality (NAHQ) and/or Certified in Health Care Quality and Management (CHCQM) by the American Board of Quality Assurance and Utilization Review Providers. The Director is responsible for overseeing the day-to-day operational activities of the Utilization Management Program in accordance with state guidelines. The UM Director must have experience in the activities of utilization management as specified in 42 CFR §438.210. Primary functions of the Director of Utilization Management position are:
Utilization Management. Provider agrees to participate in the implementation of CMHSP and/or LRE Utilization Management program, including clinical protocols.
Utilization Management. The Contractor may establish measures that are designed to maintain quality of services and control costs and are consistent with its responsibilities to Enrollees; may place appropriate limits on a service on the basis of criteria applied under the Medicaid State Plan, and applicable regulations, such as Medical Necessity; and place appropriate limits on a service for utilization control, provided the services furnished can reasonably be expected to achieve their purpose, services supporting individuals with ongoing or chronic conditions or who require long-term services and supports are authorized in a manner that reflects the Enrollee’s ongoing need for such services and supports, and Family Planning Services are provided in a manner that protects and enables the Enrollee’s freedom to choose the method of family planning.
Utilization Management. 18.104.22.168 The Contractor shall provide assistance to Members and Providers to ensure the appropriate Utilization of resources, using the following program components: Prior Authorization and Pre-Certification, prospective review, concurrent review, retrospective review, ambulatory review, second opinion, discharge planning and case management. Specifically, the Contractor shall have written Utilization Management Policies and Procedures that: