Utilization Management Plan Sample Clauses

Utilization Management Plan. DVHA must have in effect mechanisms to detect both underutilization and overutilization of services and to assess the quality and appropriateness of care furnished to enrollees with special health care needs. DVHA has delegated the function of assessing the quality and appropriateness of care furnished to beneficiaries with special health care needs to the Department of Disabilities, Aging and Independent Living (DAIL) and the Department of Mental Health (DMH). DVHA and its IGA partners, when applicable, shall adopt practice guidelines that are based on valid clinical evidence, or based on the consensus of health care professionals, consideration of the needs of the enrollees, and consultation with health care professionals who participate in the Global Commitment to Health Demonstration and other program stakeholders. Program guidelines shall be reviewed and updated periodically as appropriate. DVHA shall disseminate guidelines in collaboration with its IGA partners and shall require the Departments to disseminate the guidelines among all of their designated providers. These practice guidelines will also be made available to enrollees upon request. Decisions for utilization management, enrollee education, coverage of services and other areas to which the guidelines apply shall be consistent with the guidelines. DVHA shall not structure compensation for any entity that conducts utilization management services in such a way as to provide incentives for the denial, limitation or discontinuation of medically necessary services to any enrollee.
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Utilization Management Plan. Prior to the execution of this Agreement, and if utilization management functions are delegated to Group by Blue Shield, Group will provide Blue Shield with a written Utilization Management Plan for the purpose of review and approval by Blue Shield. Group shall notify Blue Shield within thirty (30) days of any changes involving the rules, regulations, authorities and responsibilities for the Utilization Management Plan, which shall be subject to reasonable approval thereof by Blue Shield. The Utilization Management Plan shall include procedures approved by Blue Shield to identify, assess, establish, and implement a treatment plan for Members who have complex or serious medical conditions, and for direct access of Members to services as mandated by the BBA and related regulations. Group agrees to comply with Blue Shield’s Medical Policies. All Group denial letters shall be reviewed and approved by Blue Shield. Group agrees to cooperate with Blue Shield in furnishing the required reports identified in the Provider Manual.”
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Utilization Management Plan. DHVA must have in effect mechanisms to detect both underutilization and over utilization of services and to assess the quality and appropriateness of care furnished to enrollees with special health care needs. DVHA has delegated the function of assessing the quality and appropriateness of care furnished to beneficiaries with special health care needs to the Department of Aging and Independent Living (DAIL) and the Department of Mental Health (DMH). DVHA and its IGA partners, when applicable, shall adopt practice guidelines that are based on valid clinical evidence, or based on the consensus of health care professionals, consideration of the needs of the enrollees, and consultation with health care professionals who participate in the Global Commitment to Health Waiver and other program stakeholders. Program guidelines shall be reviewed and updated periodically as appropriate. DVHA shall disseminate guidelines in collaboration with its IGA partners and shall require the Departments to disseminate the guidelines among all of their designated providers. DVHA and its IGA partners make decision with regard to the following areas that are consistent with the practice guidelines: utilization management: enrollee education; coverage of services; and other areas to which the guidelines apply. DVHA shall not structure compensation for any entity that conducts utilization management services in such a way as to provide incentives for the denial, limitation or discontinuation of medically necessary services to any enrollee.
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Utilization Management Plan. The Utilization Management Plan may not be structured to encourage individuals or entities to deny, limit, or discontinue medically necessary services.
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Utilization Management Plan. The Utilization Plan may not be structured in such a way as to provide incentives to individuals or entities to deny, limit, or discontinue medically necessary services 5.8.1. The Contractor shall have a medical director (consultant or staff) who is qualified to provide guidance, leadership, oversight, utilization and quality assurance for the behavioral health programs. These following activities may be carried out in conjunction with the administrative staff or other clinical staff, but are the responsibility of the medical director to oversee. Utilization reviews with the following components: • Services requested in comparison to services identified as medically necessary. • A review of youth receiving medication without accompanying behavioral or therapeutic intervention • Level of Care authorized for SUD treatment services based on ASAM PPC in comparison to treatment services provided. • A review of which goals identified in the Individual Service Plan have been met, have been discontinued or have continued need. • Patterns of denials • Use of Evidence-Based and other identified practice guidelines • Use of discharge planning guidelines • Community standards governing activities such as coordination of care among treating professionals • Coordination with Tribal and Recognized American Indian Organizations (RAIO) and other Individual serving agencies 5.8.2. The Contractor must establish criteria for and document and monitor: • Consistent application of Medical Necessity criteria and Level of Care Guidelines including the use of Access to Care Standards and ASAM placement criteria • Consistent application of criteria for authorization decisions for continuing stay and discharge • Appropriate inclusion of providers in utilization decisions • Over and under-utilization of services
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Utilization Management Plan. OPSS’s Utilization Management Plan, including the VA CCN Requirements relating thereto. The OPSS Utilization Management Plan, and Provider’s responsibilities and requirements relating thereto, are part of the OPSS Policies and are available to Provider in the Provider Manual.
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Utilization Management Plan. The Utilization Plan may not be structured in such a way as to provide incentives to individuals or entities to deny, limit, or discontinue medically necessary services. 6.7.1. The Contractor shall have a medical director (consultant or staff) who is qualified to provide guidance, leadership, oversight, utilization and quality assurance for the behavioral health programs. These following activities may be carried out in conjunction with the administrative staff or other clinical staff, but are the responsibility of the medical director to oversee. Utilization reviews shall address the following components: 6.7.2. The Contractor must establish criteria for and document and monitor:
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Utilization Management Plan. The OVHA shall develop and maintain a comprehensive Utilization Management Plan to identify potential over- and under-utilization of services. The Utilization Management Plan must conform to all applicable Federal and State regulations. The OVHA shall adopt program guidelines that are based on valid clinical evidence, or based on the consensus of health care professionals, consideration of the needs of the enrollees, and consultation with health care professionals who participate in the Global Commitment to Health Waiver and other program stakeholders. Program guidelines shall be reviewed and updated periodically as appropriate. The OVHA shall disseminate the guidelines to its subcontracted Departments and shall require the Departments to disseminate the guidelines among all of their designated providers. The OVHA shall not structure compensation for any entity that conducts utilization management services in such a way as to provide incentives for the denial, limitation or discontinuation of medically necessary services to any enrollee.
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Related to Utilization Management Plan

  • 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.

  • Construction Management Plan Contractor shall prepare and furnish to the Owner a thorough and complete plan for the management of the Project from issuance of the Proceed Order through the issuance of the Design Professional's Certificate of Material Completion. Such plan shall include, without limitation, an estimate of the manpower requirements for each trade and the anticipated availability of such manpower, a schedule prepared using the critical path method that will amplify and support the schedule required in Article 2.1.5 below, and the Submittal Schedule as required in Article 2.2.3. The Contractor shall include in his plan the names and resumés of the Project Superintendent, Project Manager and the person in charge of Safety.

  • Project Management Plan Developer is responsible for all quality assurance and quality control activities necessary to manage the Work, including the Utility Adjustment Work. Developer shall undertake all aspects of quality assurance and quality control for the Project and Work in accordance with the approved Project Management Plan and

  • Management Plan The Management Plan is the description and definition of the phasing, sequencing and timing of the major Individual Project activities for design, construction procurement, construction and occupancy as described in the IPPA.

  • PERFORMANCE MANAGEMENT SYSTEM 5.1 The Employee agrees to participate in the performance management system that the Employer adopted for the employees of the Employer; 5.2 The Employee accepts that the purpose of the performance management system will be to provide a comprehensive system with specific performance standards to assist the employees and service providers to perform to the standards required; 5.3 The Employer must consult the Employee about the specific performance standards and targets that will be included in the performance management system applicable to the Employee; 5.4 The Employee undertakes to actively focus on the promotion and implementation of the key performance indicators (including special projects relevant to the employee’s responsibilities) within the local government framework; 5.5 The criteria upon which the performance of the Employee shall be assessed shall consist of two components, Operational Performance and Competencies both of which shall be contained in the Performance Agreement; 5.6 The Employee’s assessment will be based on his performance in terms of the outputs/outcomes (performance indicators) identified as per attached Performance Plan, which are linked to the KPAs, and will constitute 80% of the overall assessment result as per the weightings agreed to between the Employer and Employee; 5.7 The Competencies will make up the other 20% of the Employee’s assessment score. The Competencies are spilt into two groups, leading competencies (indicated in blue on the graph below) that drive strategic intent and direction and core competencies (indicated in green on the graph below), which drive the execution of the leading competencies. Strategic direc on and leadership People management Program and project management Financial management Change leadership Governance leadersip Moral competence Planning and organising Analysis and innova on Knowledge and informa on management Communica on Results and quality focus