Common use of Our Right to Conduct Utilization Review Clause in Contracts

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).

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).