Common use of Utilization Management Program Clause in Contracts

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 and shall cooperate in the scheduling and conduct of on-site review(s) of Utilization Management Program by BLUE CROSS. Any failure to allow or to so cooperate in such review(s) shall constitute a material breach of this Agreement. A. The Utilization Management Program shall: (1) Include the development and implementation of appropriate recommendations. (2) Include documentation of remedial procedures for instances of inappropriate or substandard services(s) and/or failure to provide Medically Necessary Covered Medical Services. (3) Assure that PARTICIPATING MEDICAL GROUP’s primary consideration is the quality of services rendered to Members. (4) Assure that all services provided to Members are Medically Necessary. (5) Work closely with BLUE CROSS SENIOR SECURE Hospitals. (6) Encompass inpatient, outpatient, and ancillary care. (7) Utilize prospective, concurrent, and retrospective review. Utilization Management for Inpatient Hospital Services shall include: (a) “Pre-Admission Review” to determine whether a scheduled inpatient admission is Medically Necessary.