Managed Care Program. SHL's Managed Care Program, using the services of professional medical peer review committees, Utilization Review Committees, and/or the Medical Director, determines whether services and supplies are Medically Necessary. The Managed Care Program helps direct care to the most appropriate setting to provide healthcare in a cost-effective manner. Benefits payable for expenses incurred in connection with Covered Services, which are not Prior Authorized by the Managed Care Program, will be reduced as shown in the Attachment A Benefit Schedule.
Managed Care Program. This section tells you about SHL’s Managed Care Program and which Covered Services require Prior Authorization.
Managed Care Program. HPN's Managed Care Program, using the services of professional medical peer review committees, utilization review committees, and/or the Medical Director, determines whether services and supplies are Medically Necessary. HPN’s Managed Care Program helps direct the patient to the most appropriate setting to provide healthcare in a cost-effective manner.
Managed Care Program. This section tells you about HPN’s Managed Care Program and which Covered Services require Prior Authorization.
Managed Care Program. CarePlus plans to participate in various types of Programs, government contracts and enter into corresponding Payor and Subscriber Agreements. Innovative agrees to participate in all of the Programs described in the Exhibits annexed hereto and made a part hereof. The terms of any Program and corresponding Payor Agreements shall be consistent with the terms of this Agreement except as identified in the applicable Exhibit. To the extent that there is a conflict between this Agreement and an Exhibit, the Exhibit shall prevail.
Managed Care Program. If the services are Medically Necessary and/or appropriate. The appropriateness of the proposed setting. The required duration of treatment or admission.
Managed Care Program. If the services are Medically Necessary and/or appropriate. • The appropriateness of the proposed setting. • The required duration of treatment or admission. Following review, HPN will complete the Prior Authorization form and send a copy to the Provider and the Member. The form will specify approved services and supplies. Prior Authorization is not a guarantee of payment.
Managed Care Program. This section tells you about SHL’s Managed Care Program and which Covered Services require Predetermination.
3.1 Managed Care Program
Managed Care Program. Contractor shall be responsible for making and maintaining contracts with a variety of providers and networks for services covered under the Contract to deliver prompt and appropriate medical care to City’s injured employees at the rates contained in this Contract, Attachment E - Discount Rates and Fees or as explicitly agreed to by City management or designee(s). City of Los Angeles Managed Care Program is designed to:
1. Protect the health and safety of City employees.
2. Provide immediate and appropriate quality medical care.
3. Return injured workers to duty in a safe, productive, and timely manner.
4. Provide these benefits at a reasonable cost to City.
5. Ensure compliance with all applicable State Workers’ Compensation Laws.
6. Prevent Fraud.
7. Increase the efficiency of the Workers’ Compensation Analyst. Contractor shall provide monthly, quarterly, and annual savings reports that clearly demonstrate savings below fee schedule and other discounts.
Managed Care Program. HPN's Managed Care Program, using the services of professional medical peer review committees, utilization review committees, and/or the Medical Director, determines whether services and supplies are Medically Necessary. HPN’s Managed Care Program helps direct the patient to the most appropriate setting to provide healthcare in a cost- effective manner. Form No. HPN-Ind_AOC(2015) Page 6 HPN's Managed Care Program requires the Member, Plan Providers and HPN to work together. • All Plan Providers have agreed to participate in HPN’s Managed Care Program. Plan Providers have agreed to accept HPN’s Reimbursement Schedule amount as payment in full for Covered Services, less the Member’s payment of any applicable Copayment, Deductible or Coinsurance amount, whereas Non-Plan Providers have not. Members enrolled under HPN’s HMO Plans who use the services of Non-Plan Providers will receive no benefit payments or reimbursement for amounts for any Covered Service, except in the case of Emergency Services or Urgently Needed Services as defined in this AOC, or other Covered Services provided by a Non-Plan Provider that are Prior Authorized by HPN’s Managed Care Program including any Prior Authorized Covered Services obtained from a Non-Plan outpatient facility, such as a laboratory, radiological facility (x-ray), or any complex diagnostic or therapeutic services. In no event will HPN pay more than the maximum payment allowance established in the HPN Reimbursement Schedule. • It is the Member's responsibility to verify that a Provider selected is a Plan Provider before receiving any non-Emergency Services and to comply with all other rules of HPN’s Managed Care Program. • Compliance by the Member with HPN’s Managed Care Program is mandatory. Failure by the Member to comply with the rules of HPN’s Managed Care Program means the Member will be responsible for costs of services received. The Medical Director and/or HPN's Utilization Review Committee will review proposed services and supplies to be received by a Member to determine: • If the services are Medically Necessary and/or appropriate. • The appropriateness of the proposed setting. • The required duration of treatment or admission. Following review, HPN will complete the Prior Authorization form and send a copy to the Provider and the Member. The form will specify approved services and supplies. Prior Authorization is not a guarantee of payment. The final decision as to whether any care should be received is between ...
