Utilization management definition

Utilization management section means “you or your authorized representative.” Your representative will also receive all notices and benefit determinations.

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Utilization management means a system for reviewing the

Utilization management means a set of formal techniques designed to monitor the

Examples of Utilization management in a sentence

• When Cigna chooses to terminate Provider’s participation with respect to its commercial HMO plans, the advisory review panel shall be composed of physicians and providers appointed by Cigna, including at least one representative in Provider’s specialty or a similar specialty, if available, who serve on a standing Quality Management committee or Utilization Management committee.

• Cigna’s Utilization Management requirements include, but are not limited to, the following: a) [***] from Cigna or its designee for those services and procedures for which it is required as specified in the Administrative Guidelines; b) Provider must provide Cigna or Cigna’s designee with all of the information requested by Cigna or its designee to [***]; and c) Provider will refer Participants to and/or use Participating Providers for the provision of Covered Services [***].

• Provider shall comply with the requirements of and participate in Utilization Management as specified in this Agreement and the Administrative Guidelines.

• When Cigna chooses to terminate Provider’s participation with respect to its commercial HMO plans, the advisory review panel shall be composed of physicians and Providers appointed by ▇▇▇▇▇, including at least one representative in Provider’s specialty or a similar specialty, if available, who serve on a standing Quality Management committee or Utilization Management committee.

• Nothing in this Agreement, including Provider’s participation in care collaboration, population management, pay for performance, Quality Management, Utilization Management, and other similar programs, nor any coverage determination made by Cigna or a Payor, is intended to interfere with or affect Provider’s independent judgment in providing health care services to its patients.

More Definitions of Utilization management

Utilization management means a set of formal techniques designed to monitor the use of, or evaluate the medical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings.

Utilization management means a system for reviewing the appropriate and efficient allocation of health care services under a health benefits plan according to specified guidelines, in order to recommend or determine whether, or to what extent, a health care service given or proposed to be given to a covered person should or will be reimbursed, covered, paid for, or otherwise provided under the plan. The system may include preadmission certification, the application of practice guidelines, continued stay review, discharge planning, preauthorization of ambulatory care procedures, and retrospective review.

Utilization management means a system for administering some or all of an insurer’s decision point review plan, including but not limited to, receiving and responding to decision point review and precertification requests, making determination of medical necessity, scheduling and performing independent medical examinations (IMEs) bill review and handling of provider appeals.

Utilization management means the evaluation of medical necessity and appropriateness of the use of health care services, procedures, and facilities utilized by a Covered Person under the terms of the Plan.

Utilization management means a system for reviewing the appropriate and

Utilization management means clinical management services designed to encourage proper utilization of prescription drugs in order to enhance (or not diminish) Member outcomes while managing drug benefit costs, directly and/or indirectly, for Benefit Plan and Members. Such services include, but are not limited to the following: drug list exception, prior authorization, step therapy, quantity limits and DUR.

Utilization management means a set of formal