Utilization Management and Quality Assurance Programs. Pursuant to participation in Crescent’s or Payor’s Medical Management Programs, Facility agrees to cooperate with and participate in reasonable utilization management and quality assessment programs developed by Crescent, or by a Payor or TPA for related Plan(s), and understands that failure to comply with applicable utilization requirements may result in reductions of payment to Facility, depending on the applicable program or Plan. Crescent shall, and shall contractually require Payor to, define a reasonable process by which Facility can appeal any reduction(s) in payment made pursuant to Crescent’s or Payor’s Medical Management or utilization management programs.
Utilization Management and Quality Assurance Programs. Provider agrees to comply, cooperate with, and abide by utilization management and quality assurance procedures and protocols as structured and approved by Soteria. Failure to obtain authorizations and/or provide requested documentation shall be cause for denial of payment of the claims. Provider shall not xxxx Beneficiary for services rendered which are denied for payment due to the services being deemed non-medically necessary unless the Beneficiary was informed prior to the services being rendered and agreed in writing to accept Financial responsibility for such services. From time to time, Provider may be asked to serve on a Soteria peer review committee to review documentation pursuant to Soteria cases involving Soteria Providers other than him/herself.
