Utilization review process definition

Utilization review process means utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify or deny, based in whole or in part on medical necessity to cure or relieve, treatment recommendations by physicians, as defined in Labor Code section 3209.3, prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Labor Code section 4600. The utilization review process begins when the completed DWC Form RFA, or a request for authorization accepted as complete under section 9792.9.1(c)(2), is first received by the claims administrator, or in the case of prior authorization, when the treating physician satisfies the conditions described in the utilization review plan for prior authorization.
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Utilization review process means utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, delay, or deny, based in whole or in part on medical necessity to cure or relieve, treatment recommendations by physicians, as defined in Labor Code section 3209.3, prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Labor Code section 4600. Utilization review does not include determinations of the work-relatedness of injury or disease, or bill review for the purpose of determining whether the medical services were accurately billed.
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Utilization review process means the utilization management functions thatprospectively, retrospectively, or concurrently review and approve, modify, delay or deny based in whole or in part on medical necessity to cure or relieve, treatment recommendations by physicians prior to, retrospectively, or concurrent with the provision of medical treatment. PROCEDURES FOR POLICY COMPLIANCEPolicies:1. Treatment Requests can be modified or denied only by a physician. At the Zenith, we utilize external Clinical Peer Review for denials and either external Peer Review or an internal Zenith Medical Officer for modifications. No Zenith employee may override (or attempt to override by additional opinions) a decision for coverage, modification or denial made by a Zenith Medical Officer or external Clinical Peer Review.If compensability has not yet been determined and the basis for denial is medical necessity, the denial must be rendered by external Clinical Peer Review. If the denial is based on compensability still being undetermined, then the denial must be approved by a Zenith Medical Officer. If the denial is procedural (e.g. treatment outside of the network, treatment request not made by a party authorized to treat under the law, or other reasons not based in causation or medical necessity) the underlying request for authorization does not meet the definition of a treatment request and is not subject to this policy, therefore the claim handler is authorized to respond to these requests in compliance with the law. 2. Determinations and recommendations made by a Zenith Medical Officer or external Clinical Peer Review must be followed and implemented in a timely manner subject to the Internal Review Process set out in (3) below.3. Internal Review Process: In the event an employee disagrees with or has legal process or other concerns regarding a utilization review determination made by a Zenith Medical Officer, or external Clinical Peer Review, the determination must be escalated for an interdepartmental branch staffing (with representation from claims, legal and medical management) within one business day.The employee must immediately schedule the interdepartmental file review staffing meeting to address the concerns or issues arising from the utilization review determination. The review staffing meeting must include the appropriate departmental AVP, any Zenith Medical Officer involved in the determination and if none, a Zenith Medical Officer and other appropriate Medical Management, Claims Mana...
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Examples of Utilization review process in a sentence

  • EmblemHealth will provide an external appeal application with the final adverse determination issued through EmblemHealth’s Utilization review process or its written waiver of an internal appeal.

  • The County will provide semi-automatic handguns, as per State Statutes, also ammunition and any other necessary weapons to all Deputies.

  • Utilization review process - legislative declaration - cash fund.

  • Standardized service definitions including units of service; Establishment of standards for documentation; Establishment of provider qualifications (credentials); Authorization and reauthorization of the identified services; Utilization review process: and Development of an appeal process.

  • Utilization review process calls for assessing patients at every point of entry.

  • Utilization review process encompasses intitial, concurrent and retrospective reviews.

  • Utilization review process assesses theappropriateness of admission.

  • Under the Equality Act 2010, it is unlawful to discriminate in the provision of goods and services on the basis of gender reassignment or sexual orientation.

  • Utilization review process and criteria‌Utilization review overview‌Utilization review is the process of determining whether a given service is eligible for coverage or payment under the terms of a Member’s benefits plan and/or a network Provider’s contract.In order for a service to be covered or payable, it must be listed as included in the benefits plan, it must not be specifically excluded from coverage, and it must be Medically Necessary.


More Definitions of Utilization review process

Utilization review process means utilization management functions that prospectively, retrospectively, or concurrently review and Approve, Modify, or Deny, based in whole or in part on Medical Necessity to cure or relieve, treatment recommendations by physicians (as defined in LC § 3209.3), prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to LC § 4600.
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Utilization review process means utilization management functions that prospectively, retrospectively or concurrently review and approve, modify, delay or deny, based in whole or in part on medical necessity to cure or relieve, treatment recommendations by physicians, prior to, retrospectively, or concurrent with the provisions of medical treatment services.
Sample 1Sample 2
Utilization review process means utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, delay, or deny, based in whole or in
Sample 1Sample 2
Utilization review process means utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, or deny, based in whole or in part on medical necessity to cure or relieve, treatment recommendations by physicians, as defined in Labor Code section 3209.3, prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Labor Code section 4600.
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Related to Utilization review process

  • Utilization review means the prospective (prior to), concurrent (during) or retrospective (after) review of any service to determine whether such service was properly authorized, constitutes a medically necessary service for purposes of benefit payment, and is a covered healthcare service under this plan. WE, US, and OUR means Blue Cross & Blue Shield of Rhode Island. WE, US, or OUR will have the same meaning whether italicized or not. YOU and YOUR means the subscriber or member enrolled for coverage under this agreement. YOU and YOUR will have the same meaning whether italicized or not.

  • Utilization review plan or "plan" means a written procedure for performing review.

  • Drug utilization review means an evaluation of a prescription drug order and patient records for

  • Utilization review organization means an entity that conducts utilization review, other than a health carrier performing a review for its own health benefit plans.

  • Application Review Start Date means the later date of either the date on which the District issues its written notice that the Applicant has submitted a completed Application or the date on which the Comptroller issues its written notice that the Applicant has submitted a completed Application and as further identified in Section 2.3.A of this Agreement.

  • Clinical review criteria means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services.

  • Performance Tests means the tests to be conducted on the equipment at site for checking the performance parameters of the equipment as defined in Technical Specification.

  • Expedited review means an examination, in accordance with

  • Performance Review means a summative evaluation of a teacher other than a beginning teacher and used to determine whether the teacher’s practice meets school district expectations and the Iowa teaching standards, and to determine whether the teacher’s practice meets school district expectations for career advancement in accordance with Iowa Code section 284.7.

  • Commissioning Tests means all of the procedures and tests which, in accordance with the Reasonable and Prudent Standard, and in compliance with industry guidelines, practices and standards, are:

  • Acceptance Testing mean the tests, reviews and other activities that are performed by or on behalf of Agency to determine whether the Deliverables meet the Acceptance Criteria or otherwise satisfy the Agency, as determined by the Agency in its sole discretion.

  • Acceptance Tests means those tests performed during the Performance Period which are intended to determine compliance of Equipment and Software with the specifications and all other Attachments incorporated herein by reference and to determine the reliability of the Equipment.

  • Evaluation Team means the team appointed by the City; “Information Meeting” has the meaning set out in section 2.2;

  • Summary Subcontract Report (SSR) Coordinator, as used in this clause, means the individual at the department or agency level who is registered in eSRS and is responsible for acknowledging or rejecting SSRs in eSRS for the department or agency.

  • Project Management Report means each report prepared in accordance with Section 4.02 of this Agreement;

  • Architectural Review Committee or “ARC” shall mean the architectural review committee established by the Organization to review plans submitted to the Organization for architectural review.

  • Non-Participating Certified Clinical Nurse Specialist means a Certified Clinical Nurse Specialist who does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Design Criteria Professional means a firm who holds a current certificate of registration under Chapter 481 of the Florida Statutes, to practice architecture or landscape architecture, or a firm who holds a current certificate as a registered engineer under Chapter 471 of the Florida Statutes, to practice engineering, and who is employed by or under contract to the District to provide professional architect services, landscape architect services, or engineering services in connection with the preparation of the Design Criteria Package.

  • Timeline means the list of critical dates and actions included in the Introductory Materials.

  • Mobile crisis outreach team means a crisis intervention service for minors or families of minors experiencing behavioral health or psychiatric emergencies.

  • Diagnostic clinical procedures manual means a collection of written procedures that describes each method (and other instructions and precautions) by which the licensee performs diagnostic clinical procedures; where each diagnostic clinical procedure has been approved by the authorized user and includes the radiopharmaceutical, dosage, and route of administration.

  • Participating Certified Clinical Nurse Specialist means a Certified Clinical Nurse Specialist who has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Independent testing laboratory means an independent organization, accepted by the Contracting Officer, engaged to perform specific inspections or tests of the work, either at the site or elsewhere, and report the results of these inspections or tests.

  • Commissioning test means tests applied to the Generating Facility, after completion of the construction of the Generating Facility, in order to verify that the Generating Facility may be released for Operation.

  • Performance Test means all operational checks and tests required to determine the performance parameters including inter-alia capacity, efficiency and operating characteristics of the Stores as specified in the Contract.

  • Root Cause Analysis Report means a report addressing a problem or non-conformance, in order to get to the ‘root cause’ of the problem, which thereby assists in correcting or eliminating the cause, and prevent the problem from recurring.