Utilization Review. NOTE: The Utilization Review process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. State law requires that health plans disclose to Subscribers and health plan providers the process used to authorize or deny health care services un- der the plan. Blue Shield has completed documen- tation of this process ("Utilization Review"), as required under Section 1363.5 of the California Health and Safety Code. To request a copy of the document describing this Utilization Review pro- cess, call the Customer Service Department at the telephone number indicated on your Identification Card.
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. 13 8.1 CONTRACTOR and ADMINISTRATOR shall meet upon ADMINISTRATOR’s 14 request at CONTRACTOR’s facility identified in Paragraph 6 of this Exhibit A, 15 to review and evaluate a random selection of PARTICIPANT case records. The 16 review shall include, but is not limited to, an evaluation of the necessity 17 and appropriateness of services provided and length of services. PARTICIPANT 18 cases to be reviewed shall be randomly selected by ADMINISTRATOR.
Utilization Review. CONTRACTOR and ADMINISTRATOR’s designee shall meet at least annually to review and evaluate a random selection of case records. The review may include, but is not limited to, an evaluation of the necessity and appropriateness of services provided and length of services. Cases to be reviewed shall be randomly selected by ADMINISTRATOR and may include both open and closed cases. ADMINISTRATOR may conduct a Utilization Review (UR) at CONTRACTOR’s facility referenced in Paragraph 13 of this Attachment A, with date and time determined at ADMINISTRATOR’s discretion. ADMINISTRATOR may provide oral and/or written feedback regarding the UR findings. CONTRACTOR shall comply with the findings of the UR and take corrective action accordingly. In the event CONTRACTOR, ADMINISTRATOR and COUNTY’s Children and Family Services staff representatives and/or ADMINISTRATOR’s designee are unable to resolve differences of opinion regarding the necessity and appropriateness of services and length of services, the dispute shall be submitted to COUNTY’s Director of Children and Family Services for final resolution. Nothing in this subparagraph shall affect COUNTY’s termination rights under Paragraph 40 of this Contract.
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 Xxx. § 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.