Common use of Utilization Management Program Clause in Contracts

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: A. Qualified staff responsible for the UM program. B. Contractor shall ensure that the UM program allows for a second opinion from a qualified health professional at no cost to the Enrollee. C. Established criteria for approving, modifying, deferring, or denying requested services. Contractor shall utilize evaluation criteria and standards to approve, modify, defer, or deny services. Contractor shall document the manner in which providers are involved in the development and or adoption of specific criteria used by the Contractor. D. Contractor shall communicate to health care practitioners the procedures and services that require prior authorization and ensure that all contracting providers are aware of the procedures and timeframes necessary to obtain prior authorization for these services. E. The integration of UM activities into the Quality Improvement System (QIS), described in Exhibit A, Attachment 4 Quality Improvement System, including a process to integrate reports on review of the number and types of appeals, denials, deferrals, and modifications to the appropriate QIS staff.