Utilization control definition

Utilization control means the Department has implemented a statewide program of surveillance and utilization control that safeguards against unnecessary or inappropriate use of Medicaid services, safeguards against excess payments, and assesses the quality of services available under the plan. The program meets the requirements of 42 CFR, Part 456.

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Utilization control means an overall accountability program encompassing quality management and utilization review.

Utilization control means a systematic process of

Examples of Utilization control in a sentence

Contractor shall ensure that the medical necessity of Covered Services is determined through Utilization control procedures established in accordance with Sections 8.10.2, Pre-Authorization/Review Procedures, and 8.10.3, Exceptions to Prior Authorization Requirement, unless specific Utilization control requirements are included as terms of the Contract under sections applicable to specific services.
The Contractor will ensure that the medical necessity of Covered Services is determined through Utilization control procedures established in accordance with Sections 6.5.9.3 and 6.5.9.4, unless specific Utilization control requirements are included as a term of the Contract under sections applicable to specific services.
Contractor shall ensure that the medical necessity of Covered Services is determined through Utilization control procedures established in accordance with Sections 6.5.9.3, Pre-Authorization/Review Procedures, and 6.
Coverage may not be arbitrarily denied or reduced and is subject to certain limitations in accordance with 42 CFR 438.210(a)(3)(iii) regarding: • Medical necessity determinations • Utilization control, provided the services furnished are sufficient in amount, duration or scope to reasonably be expected to achieve the purpose for which the services are furnished The MCO must develop procedures to monitor and assess its effectiveness in delivering quality health care to its Hoosier Healthwise members.
However, no Utilization control procedure, or any other policy or procedure used by Contractor, shall limit services Contractor is required to provide under this Contract.
These Utilization Management procedures shall be consistent with appropriate Utilization control requirements of 42 CFR Part 456.

More Definitions of Utilization control

Utilization control means an approved program instituted, implemented and operated by or under the authorization of a utilization review organization (URO) which effectively safeguards against unnecessary or inappropriate Medicaid/NJ FamilyCare services and assesses the quality of those services to Medicaid/NJ FamilyCare fee- for-service beneficiaries.

Utilization control means a systematic process of measures that assure overall management and cost containment of health care services.

Utilization control means the control of covered health care services to assure the use of cost efficient, medically necessary or appropriate services.

Utilization control means a systematic process of implementing measures that assure overall management and cost containment of services delivered, including compliance with practice parameters and protocols of treatment as provided for in this chapter.

Related to Utilization control

Utilization management section means “you or your authorized representative.” Your representative will also receive all notices and benefit determinations.
Utilization plan means a form and additional documentation included in all bids or proposals that demonstrates a vendor’s proposed utilization of vendors certified by the Business Enterprise Program to meet the targeted goal. The Utilization Plan shall demonstrate that the Vendor has either: (1) met the entire contract goal or (2) requested a full or partial waiver and made Good Faith Efforts towards meeting the goal.
Fertilization means the fusion of a human spermatozoon with a human ovum.
Utilization of genetic resources means to conduct research and development, [conservation, collection, characterization, among others,] [including commercialization] on the genetic and/or biochemical composition of genetic resources, and [traditional knowledge associated with genetic resources] [including through the application of biotechnology] [as defined in Article 2 of the Convention on Biological Diversity].]
Stormwater management BMP means an excavation or embankment and related areas designed to retain stormwater runoff. A stormwater management BMP may either be normally dry (that is, a detention basin or infiltration system), retain water in a permanent pool (a retention basin), or be planted mainly with wetland vegetation (most constructed stormwater wetlands).