Medical Management Programs. The Medical Management Programs are services that can help you coordinate your care and treatment. They include utilization management and care management. Blue Shield uses utilization management to help you and your providers identify the most appropriate and cost-effective way to use the Benefits of this plan. Care management and palliative care can help you access the care you need to manage serious health conditions and complex treatment plans. For written information about Blue Shield’s Utilization Management Program, visit xxxxxxxxxxxx.xxx. Coverage for some Benefits requires pre-approval from Blue Shield. This process is called prior authorization. Prior authorization requests are reviewed for Medical Necessity, available plan Benefits, and clinically appropriate setting. The prior authorization process also identifies Benefits that are only covered from Participating Providers or in a specific clinical setting. If you see a Participating Provider, your provider must obtain prior authorization when required. When prior authorization is required but not obtained, Blue Shield may deny payment to your provider. You are not responsible for Blue Shield’s portion of the Allowable Amount if this occurs, only your Cost Share. If you see a Non-Participating Provider, you or your provider must obtain prior authorization when required. When prior authorization is required but not obtained, and the services provided are determined not to be a Benefit of the plan or Medically Necessary, Blue Shield may deny payment and you will be responsible for all billed charges. You do not need prior authorization for Emergency Services or emergency Hospital admissions at Participating or Non-Participating facilities. For non-emergency inpatient services, your provider should request prior authorization at least five business days before admission. Visit xxxxxxxxxxxx.xxx and click on Prior Authorization List for more details about medical and surgical services and select prescription Drugs that require prior authorization. Drugs administered by a Health Care Provider in a Physician’s office, an infusion center, the Outpatient Department of a Hospital, or provided at home through a home infusion agency, are covered under the medical benefit and require prior authorization. Medical and prescription Drug • Surgery • Prescription Drugs administered by a Health Care Provider • Non-emergency inpatient facility services, such as Hospitals and Skilled Nursing Facilities • Non-emerge...
Medical Management Programs. Provider agrees to participate in Medical Management Programs related to Provider Services and related amendments, if any, which are provided to Provider regarding Provider Services to Members. All Medical Management Programs now or hereafter conducted directly by Crescent pursuant to this Agreement shall be conducted in a manner substantially consistent with all applicable Joint Commission and NCQA requirements, the requirements of the Healthcare Quality Improvement Act of 1986, as amended, and all other regulatory standards and criteria for such programs. Crescent or its designee may permit Payors and their designees to conduct Medical Management Programs and shall contractually require such entities to meet such legal and regulatory requirements. Crescent shall contractually require any entity which now or hereafter conducts Medical Management Program on behalf of Crescent pursuant to this Agreement to obtain Crescent’s prior written consent before modifying any Medical Management Program. Crescent will maintain copies of all Medical Management Programs conducted by Crescent or Crescent’s designee and make such copies available for inspection and copying by Provider during normal business hours. Upon agreement by Crescent to any modification of, or new implementation of, a Medical Management Program which materially affects Provider, Crescent shall provide written notice to Provider describing such modification or containing a copy of such revised or new Medical Management Program and setting forth a date by which Provider must comply with such modifications, allowing a reasonable amount of time (not less than thirty (30) days) for Provider to comply with such revisions.
