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 18 the regular academic year plus eighteen (18) additional days of service. The 19 eleventh-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 25 the option of the employee. Any regular faculty member who performs said additional 26 full or partial month shall receive 100% pro rata pay for said service.
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.
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 Xxxxx 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. Table 2: Penalty Schedule for Inappropriate Use Detail Fee Notes 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.
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. Xxxxx 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. Utilization management staff availability 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 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 Xxxxx 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
Utilization Review Process. 1. 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.
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...
