Utilization Management (UM Sample Clauses
The Utilization Management (UM) clause establishes procedures for reviewing and managing the use of healthcare services to ensure they are medically necessary and appropriate. Typically, this involves requiring pre-authorization for certain treatments, ongoing review of care, and retrospective analysis of claims to confirm that services provided align with established guidelines. By implementing these controls, the clause helps prevent unnecessary or excessive medical interventions, thereby controlling costs and promoting efficient use of healthcare resources.
Utilization Management (UM. Director who is an Ohio-licensed registered nurse or a physician with a current unencumbered license through the Ohio State Medical Board preferably with a certification as a Certified Professional in Health Care Quality (CPHQ) by the National Association for Health Care Quality (NAHQ) and/or Certified in Health Care Quality and Management (CHCQM) by the American Board of Quality Assurance and Utilization Review Providers. The UM Director is responsible for overseeing the day-to-day operational activities of the Utilization Management Program in accordance with state guidelines. The UM Director shall have experience in the activities of utilization management as specified in 42 CFR 438.210. Primary functions of the Director of Utilization Management position are to ensure:
i. There are written policies and procedures regarding authorization of services and that these are followed;
ii. Consistent application of review criteria for authorization decisions;
iii. Decisions to deny or reduce the amount of services are made by a health care professional who has appropriate clinical expertise in treating the enrollee's condition or disease;
iv. Notices of adverse action meet the requirements of 42 CFR 438.404; and
v. All decisions are made within the specified allowable time frames.
Utilization Management (UM a. The County must have documented policies and procedures for all UM activities that involve determining medical necessity, and the approval or denial of mental health services. Qualified mental health professionals must be involved in any decision- making that requires clinical judgment. The decision to deny, reduce or authorize a service that is less than requested must be made by a health professional with appropriate clinical expertise in treating the affected member’s condition(s). The County may not deny coverage, penalize providers, or give incentives or payments to providers or enrollees that are intended to reward inappropriate restrictions on care or result in the under-utilization of services. Criteria used to determine medical necessity and appropriateness must be communicated to providers. The criteria for determining medical necessity may not be more stringent than DHS 101.03 (96m), Wis. Adm. Code.
b. If the County utilizes telephone triage, nurse lines or other demand management systems, the County must document review and approval of qualification criteria of staff and of clinical protocols or guidelines used in the system. The system’s performance will be evaluated annually in terms of clinical appropriateness.
c. The prior authorization policies must specify time frames for responding to requests for initial and continued service determinations, specify information required for authorization decision, provide for consultation with the requesting provider when appropriate, and provide for expedited responses to requests for authorization of urgently needed services. In addition, the County must have in effect mechanisms to ensure consistent application of review criteria for authorization decisions (inter-rater reliability). Within the time frames specified, the County must give the member or their authorized representative and the requesting provider written notice of:
1) The decision to deny, limit, reduce, delay or terminate a service along with the reasons for the decision.
2) The member’s grievance and appeal rights, as detailed in the Member Grievances and Appeals Guide.
3) Denial of payment, at the time of any action affecting the claim. The notice(s) must adhere to the timing and content requirements detailed in the Member Grievances and Appeals Guide. Authorization decisions must be made within the following time frames and in all cases as expeditiously as the member’s condition requires:
1) Within 14 days of the receipt of the r...
Utilization Management (UM. Program
1. The Contractor shall have a Utilization Management (UM) Program assuring that beneficiaries have appropriate access to SUD services; medical necessity has been established, the beneficiary is at the appropriate ASAM level of care, and that the interventions are
Utilization Management (UM. A strategy designed to ensure that health care expenditures are restricted to those that are needed and appropriate by reviewing CDCR/CCHCS patient and/or DJJ youth medical records through the application of defined criteria and/or expert opinion. It assesses the efficiency of the health care process and the appropriateness of decision making related to the site of care, its frequency and its duration, through prospective, concurrent, and retrospective utilization reviews.
Utilization Management (UM. 1. The HMO must have documented policies and procedures for all UM activities that involve determining medical necessity, and the approval or denial of medical services. Qualified medical professionals must be involved in any decision-making that requires clinical judgment. The decision to deny, reduce or authorize a service that is less than requested must be made by a health professional with appropriate clinical expertise in treating the affected enrollee’s condition(s). Criteria used to determine medical necessity and appropriateness must be communicated to providers. The criteria for determining medical necessity may not be more stringent than HFS 101.03 (96m) Wis. Adm. Code.
2. If the HMO delegates any part of the UM program to a third party, the delegation must meet the requirements in Article II Delegations of Authority.
3. If the HMO utilizes telephone triage, nurse lines or other demand management systems, the HMO must document review and approval of qualification criteria of staff and of clinical protocols or guidelines used in the system. The system’s performance will be evaluated annually in terms of clinical appropriateness.
4. The HMO’s policies must specify time frames for responding to requests for initial and continued service determinations, specify information required for authorization decisions, provide for consultation with the requesting provider when appropriate, and provide for expedited responses to requests for authorization of urgently needed services. In addition, the HMO must have in effect mechanisms to ensure consistent application of review criteria for authorization decisions (interrater reliability).
a. Within the time frames specified, the HMO must give the enrollee and the requesting provider written notice of:
1) The decision to deny, limit, reduce, delay or terminate a service along with the reasons for the decision.
2) The enrollee’s right to file a grievance or request a state fair hearing. HMO Contract for February 1, 2006 - December 31, 2007
b. Authorization decisions must be made within the following time frames and in all cases as expeditiously as the enrollee’s condition requires:
1) Within 14 calendar days of the receipt of the request, or
2) Within three business days if the physician indicates or the HMO determines that following the ordinary time frame could jeopardize the enrollee’s health or ability to regain maximum function. One extension of up to 14 calendar days may be allowed if the enrollee request...
Utilization Management (UM. As subject to and further defined by the County/DHCS LIHP Contract, including without limitation Attachment 5 of Exhibit A and as further specified in Attachment A, Section IV(2) below:
a) Alliance will conduct UM for LIHP Covered Services pursuant to the Alliance’s policies and procedures and in accordance with the LIHP Program, with the exception of mental health benefits which will be the sole responsibility of the County and shall be conducted by the County pursuant to its own policies and procedures.
b) Alliance UM services will include i) setting up UM Criteria using the LIHP defined benefit package
Utilization Management (UM. Provider shall comply with Partners’ UM programs, quality management programs, and provider sanctions programs, provided that such programs shall not override the professional or ethical responsibility of Provider or interfere with Provider's ability to provide information or assistance to Provider’s patients. (Attachment F.a.xvii.p.319)
Utilization Management (UM. Refers to the process to evaluate the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities. Utilization Management is inclusive of utilization review and service authorization. Utilization Review (UR) – Evaluation of the clinical necessity, appropriateness, efficacy, or efficiency of core health care benefits and services, procedures or settings, and ambulatory review, prospective review, concurrent review, second opinions, care management, discharge planning, or retrospective review.
Utilization Management (UM. A. 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/or 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, were medically necessary and performed in accordance with CCHCS Medical Standards of Care. CCHCS Medical Standards of Care means InterQual® Care Planning Criteria, published by McKesson Health Solutions, LLC, except to the extent they conflict with the Inmate Medical Services Policies and Procedures (IMSP&P), except to the extent the InterQual® criteria or the IMSP&Ps conflict with Articles 8 and 9, of Subchapter 4, of Chapter 1, of Division 3, of Title 15 of the California Code of Regulations. Requests for InterQual® criteria should be directed to ▇▇@▇▇▇▇.▇▇.▇▇▇ and the IMSP&Ps are available at ▇▇▇▇://▇▇▇.▇▇▇▇▇.▇▇.▇▇▇/imspp.aspx.
B. Contractor agrees to make available to CDCR/CCHCS for purposes of utilization review, an individual CDCR/CCHCS patient’s and/or DJJ youth’s medical record upon request from a CDCR/CCHCS UM physician or UM nurse. Contractor agrees that Contractor’s discharge protocols may not be applicable to all CDCR/CCHCS cases and that discharge determinations shall be with the concurrence of the CDCR/CCHCS attending physician.
C. Contractor acknowledges and agrees to inform its providers that UM decisions shall not be deemed a substitute for the independent judgment of the treating physician or preclude treatment but shall be cause for denial of compensation for such treatment or hospitalization found to be inappropriate, whether identified through prospective, concurrent, or retrospective utilization review.
D. Contractor acknowledges and agrees that concurrent utilization management review shall not operate to prevent or delay the delivery of emergency medical treatment.
Utilization Management (UM. The process of evaluating necessity, appropriateness and efficiency of healthcare services through the revision of information about hospital, service or procedure from patients and/or providers to determine whether it meets established guidelines and criteria approved by the ADMINISTRATION, the HCO and TPA as applicable.