UTILIZATION MANAGEMENT, QUALITY MANAGEMENT AND GRIEVANCE PROCEDURE Sample Clauses

UTILIZATION MANAGEMENT, QUALITY MANAGEMENT AND GRIEVANCE PROCEDURE. (a) Utilization Management Program: A Utilization Management Program may be established to review the medical necessity of Covered Services furnished by Physician to Plan Members on an inpatient and outpatient basis. Such program may be established by the Los Alamos PHO, in its sole and absolute discretion, and may include prior authorization of services, concurrent case management, discharge planning and retrospective review and shall be in addition to any Utilization Management program required by the conditions or provisions of a Plan. Physician shall comply with and shall be bound by the Utilization Management programs of the Los Alamos PHO and Plans with which the Los Alamos PHO has contracted with on behalf of Physician. If requested, Physician shall serve on the Utilization Management committee of such program(s) in accordance with the procedures established by the Los Alamos PHO and the Plans. Physician agrees that the decisions of the Los Alamos PHO or Plan Utilization Management committee may be used to deny Physician payment hereunder for those Covered Services provided to a Plan Member, which are determined not to be medically necessary (as defined by Los Alamos PHO or a Health Benefit program) or for which Physician failed to receive a prior authorization, if required by Los Alamos PHO or Plan policies, to treat a Plan Member. Failure to comply with the requirements of this Section 7 (a) may be deemed by the Los Alamos PHO to be a material breach of this Agreement and may, at Los Alamos PHO option, be grounds for immediate termination of this Agreement.