Quality Assurance Programs. Provider agrees to participate in any and all quality improvement and utilization management programs implemented by Blue Shield as more fully described in the Provider Manual. Moreover, Provider agrees to participate in Blue Shield’s provider credentialing and recredentialing programs. If Provider concludes that care recommended or authorized through the utilization management program is medically inappropriate for the Member, Provider may access the expedited appeal process as described in the Provider Manual. Provider may also furnish that care which Provider, in the exercise of good medical judgment, believes is medically appropriate and may appeal any coverage denial by Blue Shield in accordance with the provisions of Article VIII hereof.
Quality Assurance Programs. Contractor has sole responsibility for the quality assurance and quality control of the Work, including all work of its Subcontractors. Contractor shall use effective quality assurance programs throughout the performance of the Work that are substantially similar to those set forth in Exhibit L. Within sixty (60) days after the Effective Date, Contractor shall provide for Owner’s review Site-specific quality assurance program documentation and shall incorporate all reasonable edits from Owner.
Quality Assurance Programs. The goal of the our Quality Program is to ensure the provision of consistently excellent health care, health information and service to you, enabling you to maintain and improve your physical and behavioral health and well-being. Some components of the quality program are directed to all Covered Persons and others address specific medical issues and providers. Examples of quality activities in place for all Covered Person’s include a systematic review and re-review of the credentials of Network providers and contracted facilities, as well as the development and dissemination of clinical standards and guidelines in areas such as preventive care, medical records, appointment access, confidentiality, and the appropriate use of drug therapies and new medical technologies. Activities affecting specific medical issues and providers include disease management programs for those with chronic diseases like asthma, diabetes and congestive heart failure, and the investigation and resolution of quality-of-care complaints registered by individual Covered Persons. Pre-Existing Conditions Your coverage in this health plan is not limited based on medical conditions that are present on or before your effective date. This means that your health care services will be covered from the effective date of your coverage in this health plan without a pre-existing condition restriction or a waiting period. But, benefits for these health care services are subject to all provisions of this health plan.
Quality Assurance Programs. The State shall develop and implement quality assurance programs for protection from harm, suicide prevention, mental health care, medical care, special education services and fire safety. Compliance Rating Substantial Compliance (as of June 30, 2008) Discussion The Department has implemented a high-quality, comprehensive Quality Assurance program that will provide a sound mechanism for on-going review to ensure that the protections offered by the provisions of this Agreement remain in effect. The Department created a set of standards modeled after the provisions contained in this Agreement in the areas of protection from harm (which includes Fire Safety), special education, medical, and mental health. The first comprehensive audit at BCJJC occurred in December 2007, although it did not address mental health or special education and had a number of structural deficiencies. During the current monitoring period, a comprehensive audit of all areas of facility operations was conducted in April 2008. A targeted review was conducted in January 2008 and covered incident reporting, senior management review, seclusion and school attendance. The Quality Assurance team includes a Director and subject-matter experts in protection from harm (n=2, plus peer reviewers from other facilities), medical, mental health and education. Not only are the staff extremely well-qualified, but they are also dedicated QA staff and therefore do not have to divert their attention to other duties. As a result, the QA process is both efficient and thorough. The written report of the findings in each area was of very high quality and remediated all of the deficits noted in the prior Monitors’ Report. In addition to the reports for BCJJC, the DJS and the Monitor used reports from other DJS facilities to enhance the reporting template and refine the content. The QA reports now feature: • A clear description of the rating scale used to evaluate compliance; • The full text of each standard, which will make the reports fit for broad distribution to those who may not be familiar with the QA process; • The methodology for assessing each standard (e.g., sampling, sources of information, tools used to collect and evaluate data); • The detailed findings in each area, along with examples to illustrate systemic deficiencies; and • A list of items requiring corrective action. Further, the QA reports and targeted reviews are also designed to provide technical assistance and guidance to help the faciliti...
Quality Assurance Programs. The State shall develop and implement quality assurance programs for protection from harm, suicide prevention, mental health care, medical care, special education services, and fire safety.
Quality Assurance Programs. The State shall create or modify and implement quality assurance programs consistent with generally accepted professional standards for each of the substantive remedial areas addressed in this Agreement. In addition, the State shall:
Quality Assurance Programs. Master Broker expressly agrees to abide by any Quality Assurance Programs determined in the sole discretion of Horizon BCBSNJ. Horizon BCBSNJ agrees to provide Master Broker with thirty (30) days advance written notice of the program details prior to it becoming subject to any Horizon BCBSNJ Quality Assurance Programs.
Quality Assurance Programs. Use effective quality assurance programs throughout the performance of the Work. Within [forty-five (45)] days after the Full Notice to Proceed Date, Contractor shall provide draft quality assurance program for Owner review. Within [sixty (60)] days after the Full Notice to Proceed Date, Contractor and Owner shall agree on a quality assurance program to be used by Contractor in the performance of the Work. Contractor shall perform the Work in accordance with the approved quality assurance program.
Quality Assurance Programs. Provider agrees to participate in any and all quality improvement and utilization management programs implemented by Health Plan as more fully described in the Provider Manual. Moreover, Provider agrees to participate in Health Plan’s provider credentialing and recredentialing programs. If Provider concludes that care recommended or authorized through the utilization management program is medically inappropriate for the Member, Provider may access the expedited appeal process as described in the Provider Manual. Provider may also furnish that care which Provider, in the exercise of good medical judgment, believes is medically appropriate and may appeal any coverage denial by Health Plan in accordance with the provisions of Article VIII hereof.
Quality Assurance Programs. Blue Cross and Blue Shield uses quality assurance and training programs and performance measures that are designed to ensure accuracy in claims processing. Blue Cross and Blue Shield also uses management and technology solutions to help Member Service representatives resolve issues quickly and accurately. Services Furnished by Non-Preferred Vision Care Providers As a member of this vision care plan, you will usually receive the highest benefit level (your in-network benefits) only when you obtain covered services from a preferred vision care provider. There are a few times when this vision care plan will provide in-network benefits for covered services you receive from a non-preferred vision care provider. If you receive covered services from a non-preferred vision care provider, you will receive in-network benefits only when: • You receive emergency care. • You receive covered services that are not reasonably available from a preferred vision care provider and you had prior approval from Blue Cross and Blue Shield to obtain these covered services. • You receive covered services from a covered vision care provider before a preferred network is established for that type of provider.
