Medical Management Procedures Sample Clauses

Medical Management Procedures. The following is a description of the PPO’s medical management procedures. a) Non-emergency inpatient admissions and certain designated services and procedures identified in this Section received from Non-Preferred Providers or Preferred Providers REQUIRE Precertification by the PPO as set forth in this Section. b) The PPO case management nursing staff is available to work with Members who require transplants, who have catastrophic disease or injury, are temporarily outside the Service Area and require Urgent Care, who can benefit from individualized attention to coordinate their needs, or who are otherwise recommended for case management. c) The PPO medical management staff coordinates with the quality improvement staff to collect data and review issues to assure appropriate care in the most efficient manner. d) Concurrent review (a review of the Member’s care while under an ongoing course of treatment) may be required for services such as, but not limited to, inpatient admissions (including emergencies and admissions where the PPO is not the primary payor), home health care and outpatient rehabilitation. Concurrent review is the responsibility of the facility, not the Member. e) A PPO Medical Director will be involved in any decision to deny coverage on the basis of Medical Necessity. The PPO’s medical management policies and procedures comply with all applicable state and federal regulations regarding medical management and utilization.