Organization Determination Process Sample Clauses

Organization Determination Process. Blue Shield may delegate the process of utilization management to the Group. If such delegation occurs, Group shall comply with Medicare regulations and CMS instructions pertaining to timely organization determinations by Group as to whether to provide, deny, reduce or discontinue a Covered Service to a Member. Such determinations shall be made in accordance with procedures and instructions set forth in the Provider Manual. Group shall submit to Blue Shield on a monthly basis a report which tracks the requests for organization determinations and expedited reviews and the timeframe within which decisions were made by Group. This section is subject to change as determined by CMS regulations, policies and instructions.