Utilization Management Activities. If the Contractor provides compensation to individuals or entities to conduct utilization management activities, compensation for these activities must not be structured so as to provide incentives for the individual or entity to deny, limit or discontinue medically necessary services to any Enrollee.
Utilization Management Activities. If the Contractor provides compensation to individuals or entities to conduct utilization management activities, compensation for these activities must not be structured so as to provide incentives for the individual or entity to deny, limit or discontinue medically necessary services to any Enrollee. Primary, Acute, and Preventive Care PCP Clinical Responsibilities The PCP must: Provide overall clinical direction and serve as a central point for the integration and coordination of the Covered Services listed in Appendix A. For individuals with Complex Care Needs, a PCT must be created and the PCP must participate as needed (see Section 2.4.B.2; and Assume clinical responsibility for each Enrollee upon the effective date of enrollment including, but not limited to: Making an initial clinical determination of Emergency Conditions, Urgent Care, or routine Enrollee status; Providing for the transition of existing services, equipment, and other resources to ensure safe, efficient continuity of care at enrollment; Providing primary medical services, including acute and preventive care; and Referring the Enrollee to specialty, long term care, and behavioral health Providers, as medically appropriate. Care Management Responsibilities of the PCP or his or her designee on the PCT. As the manager of care, the PCP or the PCP’s designee must: With the Enrollee and the Enrollee’s designated representative, if any, develop an IPC; In the presence of Complex Care Needs, implement a comprehensive evaluation process to be performed by a PCT, which will include an in-home or in-facility component. Enrollees with Complex Care Needs will have their care managed by a PCT; On an ongoing basis, consult with and advise acute, specialty, long term care, and behavioral health Providers about care plans and clinically appropriate interventions; Conduct Ongoing Assessments appropriately and, as required in this Contract, adjust Individualized Plans of Care as necessary and with enrollee’s knowledge, and communicate the information to the Enrollee’s Providers in timely manner; With the assistance of the GSSC, if any, promote independent functioning of the Enrollee and provide services in the most appropriate, least restrictive environment; Document and comply with advance directives about the Enrollee's wishes for future treatment and health care decisions; Assist in the designation of a health care proxy, if the Enrollee wants one; Maintain the CER, including but not limited to appro...
