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

• Utilization management decisions are based only on appropriateness of care and service.

• Utilization management strategies such as quantity limits, step therapy and prior authorization criteria are reviewed and approved by the P & T Committee.

• Utilization management activities, including prior authorization reviews, shall be conducted by individuals with clinically appropriate backgrounds in a manner that results in interrater reliability sufficient to indicate the appropriateness and validity of the process, including the training given to the reviewers.

• Utilization management strategies such as quantity limits, step therapy and Prior Authorization criteria are reviewed and approved by the P & T committee.

• Utilization management decisions shall only affect reimbursement of Provider for services rendered and shall not limit the performance of the services of Provider or affect professional judgment.

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 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 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 a system for reviewing the appropriate and

Utilization management means a broad collection of standard clinical products and services that may be selected by Employer that are designed to encourage proper drug utilization in order to enhance member outcomes while managing drug benefit costs for Employer. Such services include, but are not limited to: Formulary exception, prior authorization, step therapy, quantity limits and retrospective DUR.

Utilization management. The process of evaluating the necessity, appropriateness and efficiency of health care services against established guidelines and criteria.