Our Right to Conduct Utilization Review Sample Clauses

Our Right to Conduct Utilization Review. To be sure a member receives appropriate benefits; we reserve the right to do utilization review. We also reserve the right to contract with an organization to conduct utilization review on our behalf. If another company does utilization review on our behalf, the company will act as an independent contractor. The company is not a partner, agent, or employee of Blue Cross & Blue Shield of Rhode Island. This agreement provides coverage only for medically necessary care. The determination, by an entity conducting utilization review, whether a service is medically necessary is solely for the purpose of claims payment and the administration of your health benefit plan. It is not a professional medical judgment. Although we may conduct utilization review, Blue Cross & Blue Shield of Rhode Island does not act as a health care provider. We do not furnish medical care. We do not make medical judgments. You are not prohibited from having a treatment or hospitalization for which reimbursement has been denied. Nothing here will change or affect your relationship with your provider(s).
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Our Right to Conduct Utilization Review. To be sure a member receives appropriate benefits; we reserve the right to do utilization review. We also reserve the right to contract with an organization to conduct utilization review on our behalf. If another company does utilization review on our behalf, the company will act as an independent contractor. The company is not a partner, agent, or employee of BCBSRI. This agreement provides coverage only for medically necessary care. The determination, by an entity conducting utilization review, whether a service is medically necessary is solely for the purpose of claims payment and the administration of your health benefit plan. It is not a professional medical judgment. Although we may conduct utilization review, BCBSRI does not act as a health care provider. We do not furnish medical care. We do not make medical judgments. You are not prohibited from having a treatment or hospitalization for which reimbursement has been denied. Nothing here will change or affect your relationship with your provider(s).
Sample 1Sample 2Sample 3See All (29)
Our Right to Conduct Utilization Review. To be sure a member receives appropriate benefits; we reserve the right to conduct utilization review. We also reserve the right to contract with an organization to do utilization review on our behalf. If another company does utilization review on our behalf, the company will act as an independent contractor. The company is not a partner, agent, or employee of Blue Cross & Blue Shield of Rhode Island. This agreement provides coverage only for dentally necessary care. The determination, by an entity conducting utilization review, whether a service is dentally necessary is solely for the purpose of claims payment and the administration of your dental benefit plan. It is not a professional dental judgment. Although we may conduct utilization review, Blue Cross & Blue Shield of Rhode Island does not act as a dentist. We do not furnish dental care. We do not make dental judgments. You are not prohibited from having a treatment for which reimbursement has been denied. Nothing here will change or affect your relationship with your dentist(s).
Sample 1Sample 2Sample 3See All (12)

Related to Our Right to Conduct Utilization Review

  • RIGHT TO CONDUCT AUDIT The IOP grants the United States General Accounting Office (GAO) the right to conduct audits. ARTICLE 11

  • Professional Conduct The Firm shall ensure compliance with all applicable standards of ethics and rules of professional responsibility, including the Florida Rules of Professional Conduct promulgated by the Florida Supreme Court for attorneys practicing in Florida (or similar standards applicable to attorneys practicing outside the State of Florida). Such standards include rules related to conflicts of interest and confidentiality that are intended to protect Citizens and Citizens’ information.‌‌

  • SUPPLIER STANDARDS OF CONDUCT Accenture is committed to conducting its business free from unlawful, unethical or fraudulent activity. Supplier will act in a manner consistent with the ethical and professional standards of Accenture as described in the Accenture Supplier Standards of Conduct, including prompt reporting of unlawful, fraudulent or unethical conduct. A copy of these standards can be found at xxxxxxxxx.xxx/xx- en/company-ethics-code.

  • Quality Assurance Program An employee shall be entitled to leave of absence without loss of earnings from her or his regularly scheduled working hours for the purpose of writing examinations required by the College of Nurses of Ontario arising out of the Quality Assurance Program.

  • Office of Inspector General Investigative Findings Expert Review In accordance with Senate Bill 799, Acts 2021, 87th Leg., R.S., if Texas Government Code, Section 531.102(m-1)(2) is applicable to this Contract, Contractor affirms that it possesses the necessary occupational licenses and experience.

  • Arbitration (Conduct of) a. All grievances shall be heard by a single arbitrator unless the parties mutually agree to submit a grievance to a three-person arbitration board.

  • PROCUREMENT ETHICS Contractor understands that a person who is interested in any way in the sale of any supplies, services, construction, or insurance to the State of Utah is violating the law if the person gives or offers to give any compensation, gratuity, contribution, loan, reward, or any promise thereof to any person acting as a procurement officer on behalf of the State of Utah, or who in any official capacity participates in the procurement of such supplies, services, construction, or insurance, whether it is given for their own use or for the use or benefit of any other person or organization.

  • Business Conduct Merger Sub was incorporated on November 5, 2020. Since its inception, Merger Sub has not engaged in any activity, other than such actions in connection with (a) its organization and (b) the preparation, negotiation and execution of this Agreement and the Transactions. Merger Sub has no operations, has not generated any revenues and has no assets or liabilities other than those incurred in connection with the foregoing and in association with the Merger as provided in this Agreement.

  • Contractor Staff Conduct 1. For reasons of safety and public policy, in any Contract resulting from this procurement, the use of illegal drugs and/or alcoholic beverages by the Contractor or its agents, employees, partners or Subcontractors shall not be permitted while performing any phase of the work herein specified.

  • Standards of Conduct Whenever the Member is required or permitted to make a decision, take or approve an action, or omit to do any of the foregoing, then the Member shall be entitled to consider only such interests and factors, including its own, as it desires, and shall have no duty or obligation to consider any other interests or factors whatsoever. To the extent that the Member has, at law or in equity, duties (including, without limitation, fiduciary duties) to the Company or other person bound by the terms of this Agreement, the Member acting in accordance with the Agreement shall not be liable to the Company or any such other person for its good faith reliance on the provisions of this Agreement. The provisions of this Agreement, to the extent that they restrict the duties of the Member otherwise existing at law or in equity, replace such other duties to the greatest extent permitted under applicable law.

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