Utilization Review Process Sample Clauses

Utilization Review Process. 3 Faculty member requests for utilization of professional development funds shall be 4 referred through the appropriate manager to the professional development committee 5 at the College. After evaluating the request, the Committee shall make an advisory 6 recommendation to the President. The President shall evaluate the recommendation 7 within 10 days. Should the President be inclined to overrule the Committee, he or 8 she shall refer the matter back to the Committee for reconsideration within ten 9 days, and shall meet with the Committee upon its request. If the Committee and 10 President disagree, the matter will be referred to the Chancellor/designee for final 11 determination, which shall not be subject to the grievance procedure. In reviewing the 12 Committee’s advisory recommendations, the President and Chancellor/designee shall 13 rely primarily upon the advice and judgment of the Committee. 15 F. District Office of Staff Development 17 Eleventh-month Contract: An eleventh-month contract is defined as covering the 18 regular academic year plus eighteen (18) additional days of service. The eleventh- 19 month consists of the eighteen (18) days. 21 As a term of this Article 25, a full or partial eleventh-month assignment shall be 22 considered as an extra-duty assignment. Faculty members shall not be required to 24 consent; said additional full or partial eleventh-month assignment shall be entirely at the 25 option of the employee. Any regular faculty member who performs said additional full 26 or partial month shall receive 100% pro rata pay for said service. 28 1. The District Officer of Staff Development shall be a faculty member. The standard 29 minimum assignment shall be for 10 months. The term of office shall be for two (2) 30 years with an option of two one (1) year extensions, but not to exceed four 31 consecutive years. The option of extension shall be contingent upon a positive 32 evaluation from a majority of the Professional Development Committee chairs after 33 consulting with their Professional Development Committees. The chairs shall 34 evaluate the District Officer and make their recommendation to the Vice 35 Chancellor of Educational Services by April 15. If the Vice Chancellor accepts the 36 recommendation, he/she shall notify the District Staff Development Officer and the 37 chairs. If the decision is to continue for another year, it shall be done. If the 38 decision is not to continue, the Vice Chancellor will advertise the vacanc...
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Utilization Review Process. Fire Department emergency ambulance use will be reviewed by the EMS Agency Contract Manager. The EMS Agency has established a mechanism for review of all fire department transports covered under this Agreement. This process is contained within the Santa ▇▇▇▇▇ County Prehospital Care Manual, Reference Section which may be modified from time to time. Transports executed in violation of the established criteria may result in penalties as identified in the table below. First violation $5,000.00 Penalty to be debited from the first responder incentive payment or by direct payment to the County for deposit to the EMS Trust Fund. Second violation within 12 months. $5,000.00 Penalty to be debited from the first responder incentive payment or by direct payment to the County for deposit to the EMS Trust Fund. Third (and beyond) violation within 12 months. $5,000.00 Penalty to be debited from the first responder incentive payment or by direct payment to the County for deposit to the EMS Trust Fund. Fourth violation within 12 months. $5,000.00 per occurrence* Penalty to be debited from the first responder incentive payment or by direct payment to the County for deposit to the EMS Trust Fund. *In addition to fines, the provider's ambulance permit may be censured including suspension or revocation.
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Utilization Review Process. 3 Faculty member requests for utilization of professional development funds shall be 4 referred through the appropriate manager to the professional development committee 5 at the College. After evaluating the request, the Committee shall make an advisory 6 recommendation to the President. The President shall evaluate the recommendation 7 within 10 days. Should the President be inclined to overrule the Committee, he or 8 she shall refer the matter back to the Committee for reconsideration within ten 9 days, and shall meet with the Committee upon its request. If the Committee and 10 President disagree, the matter will be referred to the Chancellor/designee for final 11 determination, which shall not be subject to the grievance procedure. In reviewing the 12 Committee’s advisory recommendations, the President and Chancellor/designee shall 13 rely primarily upon the advice and judgment of the Committee.
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Utilization Review Process. All determinations to deny or limit an admission, service, procedure or extension of stay shall be rendered by a physician. The determination shall be directly communicated by the physician to the provider or, if this is not possible, the provider shall be supplied with the physician's name, telephone number, and where he or she can be reached. The physician shall be available immediately in urgent or emergency cases and on a timely basis for all other cases as required by the medical exigencies of the situation. The physician shall be under the clinical direction of the medical director responsible for medical services provided to the HMO's New Jersey members. Such determinations shall be made in accordance with clinical and medical necessity criteria developed pursuant to N.J.A.C. 11:24-8.1(b) and the evidence of coverage. Utilization management determinations shall be based on written clinical criteria and protocols developed with involvement from practicing physicians and other licensed health care providers within the network and based upon generally accepted medical standards. These criteria and protocols shall be periodically reviewed and updated, and shall, with the exception of internal or proprietary quantitative thresholds for utilization management, be readily available, upon request, to members and participating providers in the relevant practice areas.
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Utilization Review Process. A basic condition of IBC’s, and its subsidiary QCC Insurance Company’s (“the Carrier”) benefit plan coverage is that in order for a health care service to be covered or payable, the services must be Medically Appropriate/Medically Necessary. To assist the Carrier in making coverage determinations for requested health care services, the Carrier uses established IBC Medical Policies and medical guidelines based on clinically credible evidence to determine the Medical Appropriateness/Medical Necessity of the requested services. The appropriateness of the requested setting in which the services are to be performed is part of this assessment. The process of determining the Medical Appropriateness/Medical Necessity of requested health care services for coverage determinations based on the benefits available under a Covered Person’s benefit plan is called utilization review. It is not practical to verify Medical Appropriateness/Medical Necessity on all procedures on all occasions; therefore, certain procedures may be determined by the Carrier to be Medically Appropriate/Medically Necessary and automatically approved based on the accepted Medical Appropriateness/Medical Necessity of the procedure itself, the diagnosis reported or an agreement with the performing Provider. An example of such automatically approved services is an established list of services received in an emergency room which has been approved by the Carrier based on the procedure meeting emergency criteria and the severity of diagnosis reported (e.g. rule out myocardial infarction, or major trauma). Other requested services, such as certain elective Inpatient or Outpatient procedures may be reviewed on a procedure specific or setting basis. Utilization review generally includes several components which are based on when the review is performed. When the review is required before a service is performed it is called a Precertification review. Reviews occurring during a hospital stay are called a concurrent review, and those reviews occurring after services have been performed are called either retrospective or post-service reviews. The Carrier follows applicable state and federally required standards for the timeframes in which such reviews are to be performed. Generally, where a requested service is not automatically approved and must undergo Medical Appropriateness/Medical Necessity review, nurses perform the initial case review and evaluation for coverage approval using the Carrier’s Medical Poli...
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Utilization Review Process. Utilization review to determine medical necessity is based on clinical criteria specific to the condition or service under review. Consideration is given to the individual’s needs including, but not limited to, status, co-morbidities, psychosocial, environmental, special needs, response to treatment, and prior use of diagnostic services, if applicable. ▇▇▇▇▇ Vision’s written agreements with participating providers define “medically appropriate/medical necessity” as a vision care service or treatment that: • is appropriate to evaluate, diagnose or treat an illness, injury, disease, or its symptoms and • is in accordance with the “Generally Accepted Standards of Medical Practice” and • is clinically appropriate considered effective for the member’s illness, injury or disease and • is not primarily for the convenience of the member or the provider and • is not more costly than an alternative service that are likely to produce equivalent results. Utilization review professionals may not accept anything of value given to their employees, agents or contractors based on: (i) either a percentage of the amount by which a claim is reduced for payment, or the number of claims or the costs of services for which the person has denied authorization or payment; or (ii) any other method encouraging the rendering of an adverse determination. For routine utilization-related inquiries, the HMO shall provide all members and providers with a toll free telephone number by which to contact utilization management staff on at least a five-day, 40 hours a week basis. Prior approval or prospective review involves services that have not yet been rendered. All pre-service reviews are for non-urgent care as services and materials for urgent/emergency care are not covered under ▇▇▇▇▇ Vision plans. Prior Approval Representatives are available during normal business hours, Monday through Friday, from 8:00 a.m. until 4:30 p.m. EST. Practitioners requesting prior approval of services complete a Prior Approval Form including, but not limited to, the following information: • Member and/or patient’s identification number • Patient’s name • Diagnosis • Requested service or procedure
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Related to Utilization Review Process

  • 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 Sub- scribers and health plan providers the process used to authorize or deny health care services under the plan. Blue Shield has completed documentation of this process ("Utilization Review"), as required un- der Section 1363.5 of the California Health and Safety Code. To request a copy of the document describing this Utilization Review process, call the Customer Service Department at the telephone number indicated on your Identification Card.

  • Review Process A/E's Work Product will be reviewed by County under its applicable technical requirements and procedures, as follows:

  • Review Protocol A narrative description of how the Claims Review was conducted and what was evaluated.

  • Project Review A. Programmatic Allowances 1. If FEMA determines that the entire scope of an Undertaking conforms to one or more allowances in Appendix B of this Agreement, with determinations for Tier II Allowances being made by SOI-qualified staff, FEMA shall complete the Section 106 review process by documenting this determination in the project file, without SHPO review or notification. 2. If the Undertaking involves a National Historic Landmark (NHL), FEMA shall notify the SHPO, participating Tribe(s), and the NPS NHL Program Manager of the NPS Midwest Regional Office that the Undertaking conforms to one or more allowances. FEMA shall provide information about the proposed scope of work for the Undertaking and the allowance(s) enabling FEMA’s determination. 3. If FEMA determines any portion of an Undertaking’s scope of work does not conform to one or more allowances listed in Appendix B, FEMA shall conduct expedited or standard Section 106 review, as appropriate, for the entire Undertaking in accordance with Stipulation II.B, Expedited Review for Emergency Undertakings, or Stipulation II.C, Standard Project Review. 4. Allowances may be revised and new allowances may be added to this Agreement in accordance with Stipulation IV.A.3, Amendments. B. Expedited Review for Emergency Undertakings

  • AUDIT REVIEW PROCEDURES A. Any dispute concerning a question of fact arising under an interim or post audit of this AGREEMENT that is not disposed of by AGREEMENT, shall be reviewed by LOCAL AGENCY’S Chief Financial Officer. B. Not later than thirty (30) calendar days after issuance of the final audit report, CONSULTANT may request a review by LOCAL AGENCY’S Chief Financial Officer of unresolved audit issues. The request for review will be submitted in writing. C. Neither the pendency of a dispute nor its consideration by LOCAL AGENCY will excuse CONSULTANT from full and timely performance, in accordance with the terms of this AGREEMENT. D. CONSULTANT and subconsultant AGREEMENTs, including cost proposals and Indirect Cost Rates (ICR), may be subject to audits or reviews such as, but not limited to, an AGREEMENT audit, an incurred cost audit, an ICR Audit, or a CPA ICR audit work paper review. If selected for audit or review, the AGREEMENT, cost proposal and ICR and related work papers, if applicable, will be reviewed to verify compliance with 48 CFR Part 31 and other related laws and regulations. In the instances of a CPA ICR audit work paper review it is CONSULTANT’s responsibility to ensure federal, LOCAL AGENCY, or local government officials are allowed full access to the CPA’s work papers including making copies as necessary. The AGREEMENT, cost proposal, and ICR shall be adjusted by CONSULTANT and approved by LOCAL AGENCY Contract Administrator to conform to the audit or review recommendations. CONSULTANT agrees that individual terms of costs identified in the audit report shall be incorporated into the AGREEMENT by this reference if directed by LOCAL AGENCY at its sole discretion. Refusal by CONSULTANT to incorporate audit or review recommendations, or to ensure that the federal, LOCAL AGENCY or local governments have access to CPA work papers, will be considered a breach of AGREEMENT terms and cause for termination of the AGREEMENT and disallowance of prior reimbursed costs. E. CONSULTANT’s Cost Proposal may be subject to a CPA ICR Audit Work Paper Review and/or audit by the Independent Office of Audits and Investigations (IOAI). IOAI, at its sole discretion, may review and/or audit and approve the CPA ICR documentation. The Cost Proposal shall be adjusted by the CONSULTANT and approved by the LOCAL AGENCY Contract Administrator to conform to the Work Paper Review recommendations included in the management letter or audit recommendations included in the audit report. Refusal by the CONSULTANT to incorporate the Work Paper Review recommendations included in the management letter or audit recommendations included in the audit report will be considered a breach of the AGREEMENT terms and cause for termination of the AGREEMENT and disallowance of prior reimbursed costs. 1. During IOAI’s review of the ICR audit work papers created by the CONSULTANT’s independent CPA, IOAI will work with the CPA and/or CONSULTANT toward a resolution of issues that arise during the review. Each party agrees to use its best efforts to resolve any audit disputes in a timely manner. If IOAI identifies significant issues during the review and is unable to issue a cognizant approval letter, LOCAL AGENCY will reimburse the CONSULTANT at an accepted ICR until a FAR (Federal Acquisition Regulation) compliant ICR {e.g. 48 CFR Part 31; GAGAS (Generally Accepted Auditing Standards); CAS (Cost Accounting Standards), if applicable; in accordance with procedures and guidelines of the American Association of State Highways and Transportation Officials (AASHTO) Audit Guide; and other applicable procedures and guidelines}is received and approved by IOAI. Accepted rates will be as follows: a. If the proposed rate is less than one hundred fifty percent (150%) - the accepted rate reimbursed will be ninety percent (90%) of the proposed rate. b. If the proposed rate is between one hundred fifty percent (150%) and two hundred percent (200%) - the accepted rate will be eighty-five percent (85%) of the proposed rate. c. If the proposed rate is greater than two hundred percent (200%) - the accepted rate will be seventy-five percent (75%) of the proposed rate. 2. If IOAI is unable to issue a cognizant letter per paragraph E.1. above, IOAI may require CONSULTANT to submit a revised independent CPA-audited ICR and audit report within three (3) months of the effective date of the management letter. IOAI will then have up to six (6) months to review the CONSULTANT’s and/or the independent CPA’s revisions. 3. If the CONSULTANT fails to comply with the provisions of this paragraph E, or if IOAI is still unable to issue a cognizant approval letter after the revised independent CPA audited ICR is submitted, overhead cost reimbursement will be limited to the accepted ICR that was established upon initial rejection of the ICR and set forth in paragraph E.1. above for all rendered services. In this event, this accepted ICR will become the actual and final ICR for reimbursement purposes under this AGREEMENT. 4. CONSULTANT may submit to LOCAL AGENCY final invoice only when all of the following items have occurred: (1) IOAI accepts or adjusts the original or revised independent CPA audited ICR;