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; or 3) with respect to mental health or substance use disorder treatment, licensed Physicians or licensed, certified, registered or credentialed Health Care Professionals who specialize in behavioral health and have experience in the delivery of mental health or substance use disorder courses of treatment. 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. We will use evidence-based and peer reviewed clinical review criteria that are appropriate to the age of the patient and designated by OASAS for substance use disorder treatment or approved for use by OMH for mental health treatment. 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 www.cdphp.com. You may ask that We send You electronic notification of a Utilization Review determination instead of notice in writing or by telephone. You must tell Us in advance if You want to receive electronic notifications. To opt into electronic notifications, call the number on Your ID card or visit Our website at www.cdphp.com. You can opt out of electronic notifications at any time.
Utilization Review. Medical Management shall establish and administer a program of Utilization Review of medical care rendered by Doctor's Care that is consistent with the terms of the Payor Agreements, and Doctor's Care agrees that it and its physicians shall adhere to the advice of such program to the extent that it is consistent with the physician's professional judgment.
Utilization Review. IPA agrees to participate with PacifiCare in an ongoing utilization review program to promote efficient use of resources. The IPA's Utilization Review Committee shall meet as frequently as necessary but at least weekly. The Utilization Review Committee shall keep minutes of the committee meetings, a copy of which shall be made available to PacifiCare upon ten (10) days written notice by PacifiCare to IPA. IPA and PacifiCare shall jointly implement a utilization review system whereby IPA shall notify PacifiCare of any hospital admissions. A member of the PacifiCare medical services staff may participate in IPA's Utilization Review Committee meetings.
Utilization Review. The Plan will provide for a system of utilization review consistent with the requirements of 42 CFR § 456 and in accordance with Miss. Code Ann. § 41-83-1 et. seq. (1972, as amended). The Contractor shall have a written Utilization Review Program description which outlines the program structure and accountability and includes, at a minimum:
Utilization Review. HCT shall conduct prospective, concurrent and retrospective reviews of Covered Services in conformity with applicable state and federal laws, regulations and reporting requirements. Provider agrees to make every effort to cooperate with, participate in and abide by decisions of HCT’s utilization review. By way of illustration only, and not limitation, Provider shall use its best efforts to cooperate with HCT’s employees conducting concurrent utilization review. If there is a conflict between Provider's utilization review standards and HCT's utilization review standards, for purposes of this Agreement, the decision of HCT’s medical director, or medical director’s designee, initially shall control, however Provider shall have the right to appeal such decision under the applicable HCT provider appeal procedures.
Utilization Review. Company will make the Member's medical records and other PII and PHI available to Anthem for all lawful purposes. Company will also make such records available to federal or state authorities as required by applicable law, rule, or regulation.
Utilization Review. This program requires that the Utilization Review Service be called via an 800 number prior to an elective hospital stay, within 48 hours of an emergency hospital stay, or prior to any surgery regardless of location, other than minor surgery performed in the physician’s office. If notification is not complied with, there is a $250 penalty; however, there are no penalties for difference of opinion between the physician and the Utilization Review Service provider. Extraordinary circumstances will be taken into consideration prior to the penalty being imposed.