PACIFICARE STANDARDS FOR UTILIZATION REVIEW Sample Clauses

PACIFICARE STANDARDS FOR UTILIZATION REVIEW. Medical Group represents and warrants that Medical Group's UM Program shall be administered in accordance with PacifiCare's UM Program standards and procedures established in accordance with utilization management standards of Accreditation Organizations and shall include, but is not limited to, the following: A. Medical Group will maintain a written UM Program description that sets forth delegated utilization management and review activities, in form and content acceptable to PacifiCare. Such UM Program description shall include, at a minimum, policies and procedures to evaluate medical necessity and criteria used, information sources, and the processes used to review and approve the provision of medical services to Members. The written UM Program must include a mechanism for reviewing and updating the UM Program description on a periodic basis, but no less than once annually, subject to PacifiCare's review and approval. B. Qualified medical professionals must supervise utilization review decisions relating to preauthorization and concurrent review. A physician must conduct a medical appropriateness review on any pre-authorization or concurrent review denial; Medical Group will use physician consultants from appropriate specialty areas of medicine and surgery who are certified by the applicable American Board of Medical Specialties for pre-authorization and concurrent review activities. C. Medical Group will adopt and implement a set of written utilization review decision protocols that are based on reasonable medical evidence. Criteria to determine appropriateness of Covered Services must be clearly documented and available, upon
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