UM Program definition

UM Program means CalOptima’s Utilization Management Program.
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UM Program means CalOptima’s Utilization Management Program. 1.43.1. 44. “Preclusion List” means the CMS-compiled list of providers and prescribers who are precluded from receiving payment for Medicare Advantage (MA) items and services or Part D drugs furnished or prescribed by Medicare beneficiaries.”
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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.
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Examples of UM Program in a sentence

  • 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.

  • 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.

  • The UM Program shall be maintained in accordance with the requirements of State and Federal Law and the standards of Accreditation Organizations.

  • 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.

  • Medical Group’s failure to arrange or provide Covered Services in accordance with the standards set forth in this Agreement and PacifiCare’s QI Program and UM Program.

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

  • County shall comply with the requirements of the UM Program including, without limitation, those criteria applicable to the LHA Services as described in this Contract.

  • Medical Group and its Participating Providers shall cooperate with PacifiCare in the performance of all Managed Care Program Services and conduct their activities in a manner consistent with the provisions of this Article 4 including specifically, but without limitation, PacifiCare’s QI Program, UM Program, Credentialing Program, Member Services activities, and Claims Processing Guidelines.

  • In addition, Medical Group shall establish and maintain a quality improvement committee and a utilization management committee to assist PacifiCare in implementing the QI Program and UM Program with respect to PacifiCare Members.

  • The Utilization Management (UM) Program shall evaluate medical necessity, appropriateness and efficiency of services provided to Medi-Cal beneficiaries prospectively or retrospectively.


More Definitions of UM 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. ARTICLE II - MARYLAND MEDICAID MANAGED CARE PROGRAM A. INTERPRETATION AND ENFORCEMENT OF STANDARDS, POLICIES, AND PROCEDURES. Notwithstanding anything in this Agreement to the contrary, with respect to all Benchmarks, standards, and PHCP and Prudential relevant policies, procedures and guidelines of general application ("PHCP Policies and Procedures") which JHMSC has agreed to comply with, follow and implement under this Agreement (including, but not limited to, those set forth in this Article II and in Article IV), the following numbered principles under this Article II, Section A shall govern and control the interpretation, application and enforcement of those Benchmarks, standards, and PHCP Policies and Procedures ("Compliance Activities"): 1. It is the express intention and desire of the parties that JHMSC begin to perform all of the JHMSC Services not later than January 1, 1997, or, in the event that, despite both parties' best efforts, such deadline is missed for any of the JHMSC Services, then as soon after January 1, 1997 as reasonably possible. Further, it is the express intention and desire of the parties that JHMSC continue the performance of JHMSC Services on an uninterrupted basis throughout the term of this Agreement. Should such performance be interrupted notwithstanding the parties' best efforts to maintain uninterrupted performance, then the parties desire and intend that JHMSC's performance of JHMSC Ser-
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