UM Program definition

UM Program means CalOptima’s Utilization Management Program.

UM Program means PHCP's utilization management program, which is part of the QI Program, and involves a comprehensive effort to monitor and manage the effective, efficient and timely use of health care services. The UM Program, at a minimum, shall satisfy the utilization management requirements of the Maryland Medicaid Managed Care Program.

UM Program means either the utilization management program established and administered by KHF or the utilization management program required by a Payer in a Payer Agreement or required by an entity pursuant to an Agreement with KHF.

Examples of UM Program in a sentence

• 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 appropriate for the diagnosis and level of care.

• IEHP is responsible for maintaining a monitoring system for UM Program oversight.

• The UM Program must be evaluated, and updated if necessary, at least annually.

• Continuing Care Coordinators work within the Kaiser Permanente UM Program.

• The Medical Director and Behavioral Health Director shall supervise the UM Program and shall be accessible and available for consultation as needed.

• The Contractor shall implement a Utilization Management (UM) Program that meets the requirements set forth in this section and that is documented in a plan as defined in KRS 304.17A- 600.

• The Contractor shall have a comprehensive UM Program that reviews services for Medical Necessity and clinical appropriateness, and that monitors and evaluates on an ongoing basis the appropriateness of care and services for physical and behavioral health.

• The Semi-Annual report due in February must also include the UM Program Annual Evaluation that is the IPA’s evaluation of the overall effectiveness of the UM Program, including whether or not goals were met.C. Annual Reporting Requirements: The following reports must be submitted annually to IEHP by the last day of February of each calendar year:1.

• Counties will have a Utilization Management (UM) Program assuring that beneficiaries have appropriate access to substance use disorder services; medical necessity has been established and the beneficiary is at the appropriate ASAM level of care and that the interventions are appropriate for the diagnosis and level of care.

• The committee shall also be responsible for monitoring patterns of care, isolating inappropriate utilization and performing other management and review duties as specified in the UM Program.