Clinical Review Clause Samples

Clinical Review. ▇▇▇▇▇▇▇▇ will confirm with the prescribing physician and other health care providers whether certain Prescription Drugs are being prescribed for medical conditions consistent with FDA-approved indications and labeling. In providing any or all such services, ▇▇▇▇▇▇▇▇ may rely upon information provided by the Member or such person’s representative, the prescribing physician or health care provider, the dispensing pharmacist and other sources deemed reliable by ▇▇▇▇▇▇▇▇. Benecard shall not determine medical necessity or appropriateness of treatment. In determining if a prescription Claim is payable, Benecard may rely upon protocols established and maintained by commonly recognized medical sources or compendia or an advisory Pharmacy and Therapeutics Committee based upon factors such as safety, availability, potential for misuse and cost in its review of Claims submitted for payment of such Prescription Drugs. Group acknowledges that ▇▇▇▇▇▇▇▇ may suspend processing of Claims for Prescription Drugs subject to Clinical Review procedures in the event the prescribing physician or health care provider fails to provide any information necessary for the processing of such Claims in compliance with such protocols. The decision to prescribe and dispense any drug shall remain within the professional judgment of the physician or health care provider and the pharmacist, respectively.

Clinical Review. A clinical review is conducted by representatives from a hospital and DMH who are delegated by the DMH Commissioner to serve this function and review any materials submitted relevant to the decision. Delegated staff may issue a decision or request additional information from persons with knowledge of the issues prior to deciding. The DMH Medical Director will render a determination regarding authorizing or denying the payment. If the DMH Medical Director believes additional consultation is needed to render a determination he/she may informally consult with another

Clinical Review. Highmark shall submit the claim(s) tied to the disputed care (“disputed claim”) to teams of two clinicians, one designated by UPMC and the other by ▇▇▇▇▇▇▇▇, who have the authority to determine for each party whether the claim qualifies as In-Network under the Continuity of Care provision. The Clinical Review will occur within 15 days of submission of the disputed claim to the clinicians for review. UPMC will provide the reviewing clinicians with appropriate supporting clinical information or documentation for the claim(s).

Clinical Review. Under appropriate circumstances, individual cases may be referred to the Health Services Chief of Medicine for clinical review. The Health Services Chief of Medicine may form a review committee (sometimes referred to as a “Therapeutic Levels of Care Committee” or “TLC Committee”,) which may include one or more department providers, the Medical Services Manager, and other appropriate Department staff. The TLC Committee review care and treatment requests on a case- by-case basis, with the Health Services Chief of Medicine (or designee) as the final authority in any review. Factors that the TLC Committee may consider include, but are not limited to: (a) The urgency of the care and treatment, and the length of the AIC's remaining sentenced stay. Whether the care and treatment could be or could not be reasonably delayed without causing a significant progression, complication, or deterioration of the condition and would not otherwise be in clear violation of sound medical principles. (b) The necessity of the care or treatment, including: (i) Any relevant functional disability and the degree of functional improvement to be gained; (ii) Medical necessity, or the overall morbidity and mortality of the condition if left untreated; (iii) Pre-existing conditions, whether the condition existed prior to the AIC’s incarceration and, if treatment was not obtained previously, the reasons for not obtaining earlier treatment; (iv) The probability the procedure or therapy will have a successful outcome along CONFIDENTIAL SETTLEMENT COMMUNICATION PROTECTED BY FRE 408 with relevant risks; (v) Alternative therapy or procedures that may be appropriate; (vi) The AIC's desire for the procedure and the likelihood of the AIC's cooperation in the treatment efforts; (vii) Any known risks or benefits relative to those risks; (viii) Any known costs or benefits relative to those costs; (ix) Pain complaints or pain behaviors; and (x) Any other factors that are relevant or pertinent in light of the circumstances presented. (c) When considering whether to provide devices described in OAR 291-124-0043 (eyeglasses), OAR 291-124-0044 (hearing aids), or OAR 291-124-0045 (durable medical equipment), the TLC Committee shall consider the AIC’s ability to engage in activities of daily living and ability to access programs, services, and activities of the institution.