Quality and Utilization Management. The Practice acknowledges and agrees that a quality and utilization management program for determining the medical necessity and appropriateness of care rendered by the Practice provides controls and protections that assist to prevent potential overutilization with any fee-for-service arrangement including, but not limited to, those reimbursable under federal health insurance programs and also provides essential data to the Practice and the Company for the purposes of managing the Cancer Centers and negotiating, administering and maintaining Third-Party Payor contracts. The Practice and the Company agree to develop and implement a quality and utilization management program in accordance with recommendations made by the Company, the Practice, or the Medical Advisory Board or as required under Third-Party Payor contracts. The Practice shall cause the Physicians to participate in the development of such programs and to comply with the standards, protocols or practice guidelines established thereby, and the Practice will ensure that such individuals are required by their employment agreements or other contracts to do so. The Company is authorized by the Practice to prepare and distribute reports of such program activities to employees of, and consultants to the Practice and the Company, to Third-Party Payors, and to such other Persons as the Company deems necessary in order for the Company to carry out its obligations hereunder.
Quality and Utilization Management. VA ACKNOWLEDGES AND AGREES THAT A QUALITY AND UTILIZATION MANAGEMENT PROGRAM FOR DETERMINING THE MEDICAL NECESSITY AND APPROPRIATENESS OF CARE RENDERED BY VA PROVIDES CONTROLS AND PROTECTIONS THAT ASSIST TO PREVENT POTENTIAL OVERUTILIZATION WITH ANY FEE FOR SERVICE ARRANGEMENT, INCLUDING, BUT NOT LIMITED, TO THOSE REIMBURSABLE UNDER FEDERAL HEALTH INSURANCE PROGRAMS AND ALSO PROVIDES ESSENTIAL DATA TO VA AND MANAGER FOR THE PURPOSES OF MANAGING THE PRACTICE AND NEGOTIATING, ADMINISTERING AND MAINTAINING PAYOR CONTRACTS. VA and Manager agree to develop and implement a quality and utilization management program in accordance with recommendations made by Manager and VA, or as required under Payor Contracts. VA shall cause Physicians and employed, supervised or affiliated Allied Health Professionals to participate in the development of such programs and to comply with the standards, protocols or practice guidelines established thereby and VA will ensure that such individuals are required by their Physician Employment Agreements, Physician Independent Contractor Agreements or other contracts to do so. Manager is authorized by VA to prepare and distribute reports of such VA program activities to employees of, and consultants to, VA and Manager, to Payors, and to such other persons as Manager deems necessary in order for Manager to carry out its obligations hereunder.
Quality and Utilization Management. Provider agrees to participate in quality improvement activities, care coordination activities, grievance procedures, continuing medical education requirements and other policies and programs of the CMO as may be required from time to time. Provider shall cooperate with the CMO in satisfying the accreditation standards of NCQA and OMPP, among others. Provider agrees to participate in and cooperate with the decision, rules and regulations established by the CMO’s medical management and disease management programs. Provider also agrees to abide by the terms of the CMO's Care Select quality improvement incentive plan, if applicable.
Quality and Utilization Management. (a) Dental Specialty Provider shall participate in the Dental HMO Network Quality Assurance Program ("Program") developed by HMSA. Dental Specialty Provider may be asked to participate on one or more of the committees established by the Program. The Program shall include but is not limited to committees which address:
(1) Patient and provider grievance procedures
(2) Customer satisfaction surveys
(3) Utilization review
(4) Office audits
(5) Patient rights and responsibilities
(6) Credentialing and recredentialing
(7) Quality assurance report cards and other quality assurance activities.
(b) Upon written request, Dental Specialty Provider shall make any records of its quality assurance and utilization review activities pertaining to the Beneficiaries available to HMSA.
Quality and Utilization Management. Participating Provider shall cooperate with Avesis and Sponsor’s Quality Management and Utilization Management Program requirements. Participating Provider recognizes that Avesis shall monitor Participating Provider’s performance on an ongoing basis and subject Participating Provider to formal review according to a period schedule established by DPW, consistent with industry standards and State laws and regulations. In the event that Avesis identifies deficiencies or areas needing improvement, Avesis shall develop a corrective action plan and Participating Provider shall implement said plan.
Quality and Utilization Management. ProMedCo will assist ADC in fulfilling its obligation to its patients to maintain high quality medical and professional services, including patient satisfaction programs, employee education, outcomes analysis, utilization programs, clinical protocol development and to implement a risk management program.
Quality and Utilization Management.
(a) DVHA shall not structure compensation for any entity that conducts utilization management services in such a way as to provide incentives for the denial, limitation, or discontinuation of medically necessary services to any beneficiary.
(b) DVHA must establish and implement an ongoing comprehensive Quality Assessment and Performance Improvement (QAPI) program for the services it furnishes to its beneficiaries.
(c) DVHA’s QAPI must have in effect mechanisms to detect both underutilization and overutilization of services and to assess the quality and appropriateness of care furnished to beneficiaries with special health care needs. DVHA has delegated the function of assessing the quality and appropriateness of care furnished to beneficiaries with special health care needs to the Department of Disabilities, Aging and Independent Living (DAIL) and the Department of Mental Health (DMH).
(d) DVHA’s comprehensive QAPI program must include mechanisms to assess the quality and appropriateness of care furnished to beneficiaries using LTSS, including:
(i) An assessment of care between care settings; and
(ii) A comparison of services and supports received with those set forth in the beneficiary’s treatment/service plan.
(e) With respect to LTSS, DVHA must participate in efforts by the state to prevent, detect, and remediate critical incidents, consistent with assuring beneficiary health and welfare, that are based, at a minimum, on the requirements of the state for home and community- based waiver programs.
(f) DVHA shall, and will require its Intragovernmental Partners to, maintain an ongoing program of Performance Improvement Projects (PIPs) that focuses on clinical and non-clinical areas. Each PIP must be designed to achieve significant improvement, sustained over time, in health outcomes and beneficiary satisfaction. The PIPs shall involve the following:
(i) Measurement of performance using objective quality measures;
(ii) Implementation of system interventions to achieve improvements improvement; and
(iii) Evaluation of the effectiveness of the interventions;
(iv) Planning and initiation of activities for increasing or sustaining
(v) Reporting the status and results of each project to AHS as
(g) DVHA must adopt practice guidelines that are based on valid and reliable clinical evidence or a consensus of providers in the particular field. The practice guidelines must consider the needs of beneficiaries and must be adopted in consultation with network provide...
Quality and Utilization Management. Administrator shall provide such administrative support for Group’s quality and utilization management committee(s) and activities as reasonably requested by Group from time to time.
Quality and Utilization Management. Continuity of Care in Enrollment
Quality and Utilization Management. THE PRACTICE OPERATOR ACKNOWLEDGES AND AGREES THAT A QUALITY AND UTILIZATION MANAGEMENT PROGRAM FOR DETERMINING THE MEDICAL NECESSITY AND APPROPRIATENESS OF CARE RENDERED BY THE PRACTICE OPERATOR PROVIDES CONTROLS AND PROTECTIONS THAT ASSIST TO PREVENT POTENTIAL OVERUTILIZATION WITH ANY FEE FOR SERVICE ARRANGEMENT, INCLUDING, BUT NOT LIMITED, TO THOSE REIMBURSABLE UNDER FEDERAL HEALTH INSURANCE PROGRAMS AND ALSO PROVIDES ESSENTIAL DATA FOR THE PURPOSES OF MANAGING THE PRACTICE AND NEGOTIATING, ADMINISTERING AND MAINTAINING PAYOR CONTRACTS. The Practice Operator agrees to develop and implement a quality and utilization management program as provided herein, or as required under Payor Contracts. The Practice Operator shall cause Physicians and employed, supervised or affiliated Allied Health Professionals to participate in the development of such programs and to comply with the standards, protocols or practice guidelines established thereby and the Practice Operator will ensure that such individuals are required by their Physician Employment Agreements or other contracts to do so.
