Utilization Management Reviews Sample Clauses

Utilization Management Reviews. (1) CDCR/CCHCS reserves the right to inspect, monitor, and perform utilization reviews prospectively, concurrently, or retrospectively, regarding the courses of medical treatment or hospitalization provided to CDCR/CCHCS patients and/or DJJ youth when performed by Contractor and its providers. CDCR/CCHCS may delegate this right to another State agency or party. Such reviews shall be undertaken to determine whether the course of treatment or services had prior authorization and were medically necessary. The utilization and performance of direct health care services to CDCR/CCHCS patients and/or DJJ youth is expected to be in accordance with applicable state law for patient health care, as well as any CCHCS practice guidelines, including the Inmate Medical Services Policies and Procedures (IMSP&P), California Code of Regulations (CCR), Title 15, Division 3, Chapter 1, Subchapter 4, Articles 8 and 9, and be in accordance with the applicable standard of care. CCHCS also relies on InterQual® Care Planning Criteria, published by McKesson Health Solutions, LLC, to the extent, not inconsistent with the previously cited requirements, guidelines and standards. Requests for InterQual® criteria should be directed to CCHCS Utilization Management (UM) at: xx@xxxx.xx.xxx. IMSP&Ps are available at the following link: xxxx://xxx.xxxxx.xx.xxx/imspp.aspx.
Sample 1
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Utilization Management Reviews. (1) CDCR/CCHCS reserves the right to inspect, monitor, and perform utilization reviews prospectively, concurrently, or retrospectively, regarding the courses of medical treatment or hospitalization provided to CDCR/CCHCS patients and/or Division of Juvenile Justice (DJJ) youth when performed by Contractor and its providers. CDCR/CCHCS may delegate this right to another State agency or party. Such reviews shall be undertaken to determine whether the course of treatment or services had prior authorization and were medically necessary. The utilization and performance of direct health care services to CDCR/CCHCS patients and/or DJJ youth is expected to be in accordance with applicable state law for patient health care, as well as any CCHCS practice guidelines, including the Health Care Department Operations Manual (HCDOM), California Code of Regulations (CCR), Title 15, Division 3, Chapter 1, Subchapter 4, Articles 8 and 9 and CCR, Title 15, Division 3, Chapter 2, and be in accordance with the applicable standard of care. CCHCS also relies on InterQual® Care Planning Criteria, published by McKesson Health Solutions, LLC, to the extent, not inconsistent with the previously cited requirements, guidelines, and standards. Requests for InterQual® criteria should be directed to CCHCS Utilization Management (UM) at: xx@xxxx.xx.xxx. HCDOM is available at the following link: xxxxx://xxxxx.xx.xxx/hcdom/.
Sample 1

Related to Utilization Management Reviews

  • 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.

  • Utilization Review We review health services to determine whether the services are or were Medically Necessary or experimental or investigational ("Medically Necessary"). This process is called Utilization Review. Utilization Review includes all review activities, whether they take place prior to the service being performed (Preauthorization); when the service is being performed (concurrent); or after the service is performed (retrospective). If You have any questions about the Utilization Review process, please call the number on Your ID card. The toll-free telephone number is available at least 40 hours a week with an after-hours answering machine. All determinations that services are not Medically Necessary will be made by: 1) licensed Physicians; or 2) licensed, certified, registered or credentialed health care professionals who are in the same profession and same or similar specialty as the Provider who typically manages Your medical condition or disease or provides the health care service under review. We do not compensate or provide financial incentives to Our employees or reviewers for determining that services are not Medically Necessary. We have developed guidelines and protocols to assist Us in this process. Specific guidelines and protocols are available for Your review upon request. For more information, call the number on Your ID card or visit Our website at xxx.xxxxxxx.xxx.

  • Project Management Plan 1 3.4.1 Developer is responsible for all quality assurance and quality control 2 activities necessary to manage the Work, including the Utility Adjustment Work.

  • Project Management Services Contractor shall provide business analysis and project management services necessary to ensure technical projects successfully meet the objectives for which they were undertaken. Following are characteristics of this Service:

  • Systems Review The Construction Administrator will conduct reviews of proposed roof, structural, mechanical, electrical, plumbing, conveyance, sprinkler, telecommunications, and life safety systems, and will consider initial cost, availability, impact on the overall program, comfort and convenience, long-term maintenance and operating costs, and impacts on schedule.

  • Configuration Management The Contractor shall maintain a configuration management program, which shall provide for the administrative and functional systems necessary for configuration identification, control, status accounting and reporting, to ensure configuration identity with the UCEU and associated cables produced by the Contractor. The Contractor shall maintain a Contractor approved Configuration Management Plan that complies with ANSI/EIA-649 2011. Notwithstanding ANSI/EIA-649 2011, the Contractor’s configuration management program shall comply with the VLS Configuration Management Plans, TL130-AD-PLN-010-VLS, and shall comply with the following:

  • 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.

  • Log Reviews All systems processing and/or storing PHI COUNTY discloses to 11 CONTRACTOR or CONTRACTOR creates, receives, maintains, or transmits on behalf of COUNTY 12 must have a routine procedure in place to review system logs for unauthorized access.

  • PERFORMANCE MANAGEMENT SYSTEM 5.1 The Employee agrees to participate in the performance management system that the Employer adopts or introduces for the Employer, management and municipal staff of the Employer.

  • Project Management Project Management Institute (PMI) certified project manager executing any or all of the following: • Development of Project Charter • Development of project plan and schedule • Coordination and scheduling of project activities across customer and functional areas • Consultation on operational and infrastructure requirements, standards and configurations • Facilitate project status meetings • Timely project status reporting • Address project issues with functional areas and management • Escalation of significant issues to customers and executive management • Manage project scope and deliverable requirements • Document changes to project scope and schedule • Facilitate and document project closeout

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