Utilization Management Program. To adopt and maintain a Utilization Management Program consistent with BLUE CROSS standards and approved by BLUE CROSS. This program will cover all Covered Medical Services provided or arranged by PARTICIPATING MEDICAL GROUP for Members. PARTICIPATING MEDICAL GROUP agrees to allow on-site review of Utilization Management Program by BLUE CROSS.
Utilization Management Program. E. The Contractor shall not require prior authorization for an emergency admission for psychiatric inpatient hospital services, whether the admission is voluntary or involuntary. (Cal. Code Regs., tit. 9, §§ 1820.200(d) and 1820.225). The Contractor that is the MHP of the beneficiary being admitted on an emergency basis shall approve a request for payment authorization if the beneficiary meets the criteria for medical necessity and the beneficiary, due to a mental disorder, is a current danger to self or others, or immediately unable to provide for, or utilize, food, shelter or clothing. (Cal Code Regs, tit. 9 §§ 1820.205 and 1820.
Utilization Management Program. A process of review of the medical necessity, appropriateness and efficiency of health care services, procedures, equipment, supplies, and facilities rendered to Members.
Utilization Management Program. The Contractor shall implement a Utilization Management (UM) Program that meets the requirements set forth in this section and that is documented in a plan as defined in KRS 304.17A- 600. The UM program, processes and timeframes shall be in accordance with 42 C.F.R. 456, 42 C.F.R. 431, 42 C.F.R. 438. If the Contractor utilizes a private review agent, as defined in KRS 304.17A-600, the agent shall comply with all applicable requirements of KRS 304.17A-600 to 304.17A-633, as applicable. The Medical Director and Behavioral Health Director shall supervise the UM Program and shall be accessible and available for consultation as needed. The Contractor shall implement innovative and effective Utilization Management processes to ensure a high quality, clinically appropriate yet highly efficient and cost-effective delivery system. The Contractor shall continually evaluate the cost and quality of medical services delivered by Providers. The Contractor shall apply objective and evidence-based criteria that take the individual Enrollee’s circumstances when determining the Medical Necessity of health care services. The Contractor shall have a written plan for the UM program that details the program structure and, if delegated, includes a clear definition of authority and accountability for all activities between the Contractor and entities to which the Contractor delegates UM activities. The UM Program and Review Plan shall comply with KRS 304.17A-600 and include the following information, at a minimum:
Utilization Management Program. Contractor shall develop, implement, and continuously update and improve, a Utilization Management (UM) program that ensures appropriate processes are used to review and approve the provision of Medically Necessary Covered Services. Contractor is responsible to ensure that the UM program includes:
Utilization Management Program. A process adopted by HMO for the review of the appropriateness and necessity of health care services rendered to Members.
Utilization Management Program. The program(s) approved by PARTNERSHIP, which are designed to review and monitor the utilization of Services. Such program(s) are set forth in PARTNERSHIP’s Provider Manual.
Utilization Management Program. Provider shall cooperate and comply with and participate in any applicable utilization management programs established (or amended from time to time) by Health Plan and approved by DHCS and DMHC.
Utilization Management Program. 9.1.1 The Contractor shall have and maintain a Utilization Management Program (UMP) for the services it furnishes its enrollees.
Utilization Management Program. The Contractor shall operate and maintain its own utilization management program. The Contractor may place appropriate limits on coverage on the basis of medical necessity or utilization control criteria, provided the services furnished can reasonably be expected to achieve their purpose. The Contractor is prohibited from arbitrarily denying or reducing the amount, duration or scope of required services solely because of diagnosis, type of illness or condition. The Contractor shall establish and maintain medical management criteria and practice guidelines in accordance with state and federal regulations that are based on valid and reliable clinical evidence or consensus among clinical professionals and consider the needs of the Contractor’s members. The Contractor may accept a nationally recognized set of guidelines, including but not limited to Milliman Care Guidelines or InterQual. If the Contractor chooses to utilize separate guidelines for physical health and behavioral health services, the Contractor shall demonstrate that the use of separate guidelines would have no negative impact on members, and would not otherwise violate the Contractor’s requirements under the Mental Health Parity and Addiction Parity Act (MHPAEA). Pursuant to 42 CFR 438.210(b), relating to authorization of services, the Contractor shall consult with contracting health care professionals in developing practice guidelines and shall have mechanisms in place to ensure consistent application of review criteria for authorization decisions and consult with the provider that requested the services when appropriate. The Contractor shall have sufficient staff with clinical expertise and training to interpret and apply the utilization management criteria and practice guidelines to providers’ requests for health care or service authorizations for the Contractor’s members. The Contractor shall periodically review and update the guidelines, distribute the guidelines to providers and make the guidelines available to members upon request. Utilization management staff shall receive ongoing training regarding interpretation and application of the utilization management guidelines. The Contractor shall be prepared to provide a written training plan, which shall include dates and subject matter, as well as training materials, upon request by OMPP. The Contractor shall require its providers to utilize the standardized Indiana Health Coverage Programs Prior Authorization Request Form for the submissi...
