Quality Assurance and Utilization Review. The Advisory Board shall advise Manager and Practice regarding all quality assurance and utilization review programs undertaken by Practice either independently or in connection with any managed care contracts maintained by Practice, and Manager shall assist the Practice in preparing, reviewing, revising and performing the quality assurance and utilization review functions of the Practice in consultation with the Advisory Board. Notwithstanding any contrary provision of this Agreement, it is acknowledged and agreed that other than as provided in Section 2.2(a), recommendations of the Advisory Board are intended for the advice and guidance of Manager and Practice and that the Advisory Board does not have the power to bind Manager or Practice. Where discretion with respect to any matter is vested in Practice under the terms of this Agreement, Practice shall have ultimate responsibility for the exercise of such discretion, notwithstanding any recommendation of the Advisory Board. Where discretion with respect to any matter is vested in Manager under the terms of this Agreement, Manager shall have ultimate responsibility for the exercise of such discretion, notwithstanding any recommendation of the Advisory Board. Manager and Practice shall, however, take such recommendations of the Advisory Board into account in good faith in the exercise of such discretion.
Quality Assurance and Utilization Review. PROVIDER shall cooperate with the quality assurance and utilization review system established pursuant to Section 5179 of the California Labor Code and Section 1979 of the Rules, and shall cooperate with the Commissioner in accordance with the provisions of Section 5186 of the California Labor Code and Sections 1986 and 1986.1 of the Rules and the policies and related procedures established by IEFMC.
8.1 All treatment provided under the Workers’ Compensation Network shall be provided in accordance with the medical treatment utilization schedule established pursuant to Section 5307.27 of the American College of Occupational & Environmental Medicine’s (ACOEM) Occupational Medicine Practice Guidelines as well as any other requirements under the labor code.
8.2 For Patients being seen under Workers’ Compensation, “Medically Necessary Services” are those services that are determined to be appropriate and necessary for the symptoms, diagnosis or treatment of the medical condition, and provided for the diagnosis or direct care and treatment of the medical condition, and within standards of good medical practice with the organized community, and not primarily for the convenience of the injured worker, the physician, or any other provider’s convenience, and be the most appropriate level of service which can be safely provided.
8.3 For Patient’s being seen under Workers’ Compensation “Utilization Schedule” means the adoption by the Administrative Director of a utilization schedule presumptively correct on the issue of extent and scope of medical treatment. These guidelines are currently based on the American College of Occupational and Environmental Medicine and Occupational Medical Practice Guidelines. For injuries not covered by the ACOEM guidelines or the schedule, treatment shall be in accordance with other evidence-based medical treatment guidelines generally recognized by the medical community.
Quality Assurance and Utilization Review a. Provide supplemental nursing support services and triage services relative to Utilization Review and Quality Assurance
b. Provide Monthly/Quarterly/Annual Quality Management reports
c. Provide Daily/Weekly/Monthly Utilization Review reports for IPA’s Director/Board d. Assist Physicians and make Quality Assurance recommendations in Quality Assurance Review e. Administer grievance procedures, per Plan requirements
Quality Assurance and Utilization Review. TDAHP shall have sole responsibility for the resolution of all grievance lodged by Members, all quality assurance, and all utilization review functions as may be required by the state of Arizona in connection with TDAHP's license.
Quality Assurance and Utilization Review. Dental Source shall -------------------------------------------- have sole responsibility for the resolution of all grievance lodged by Members, all quality assurance, and all utilization review functions as may be required by the State of Missouri and Kansas in connection with Dental Source's license.
Quality Assurance and Utilization Review. TDA shall have sole responsibility for the resolution of all grievance lodged by Members, all quality assurance, and all utilization review functions as may be required by the state of Utah in connection with TDA's license.
Quality Assurance and Utilization Review. Facility agrees to comply with and participate in INSURER’S quality assurance and utilization review program. Facility agrees to comply with such other procedures and to provide other data as may be requested by INSURER or INSURER’S designee in order for INSURER or its designee to conduct quality and utilization review activities concerning services provided to INSUREDS.
Quality Assurance and Utilization Review. Provider shall participate in and cooperate with Health Plan’s utilization review program and its quality assurance and improvement programs, including the timely submission of requested data and participating in the interpretation of performance data, instituting needed change, and cooperating with appropriate remedial action.
Quality Assurance and Utilization Review. Associate Member shall participate in risk management, utilization review and management, cost- effectiveness studies and quality assurance plans as are reasonably requested by UPI or third party payors with whom UPI contracts for the services of UPI members.
Quality Assurance and Utilization Review. The Advisory Board shall advise Manager and PDS regarding all quality assurance and utilization review programs undertaken by PDS either independently or in connection with any managed care contracts maintained by PDS, and Manger shall assist PDS in performing the quality assurance and utilization review functions of PDS in consultation with the Advisory Board. Notwithstanding any contrary provision of this Agreement, it is acknowledged and agreed that other than as provided in Section 2.2(a), recommendations of the Advisory Board are intended for the advice and guidance of Manager and PDS and that the Advisory Board does not have the power to bind Manager or PDS. Where discretion with respect to any matter is vested in Manager under the terms of this Agreement, Manager shall have ultimate responsibility for the exercise of such discretion, notwithstanding any recommendation of the Advisory Board. Where discretion with respect to any matter is vested in PDS under the terms of this Agreement, PDS shall have ultimate responsibility for the exercise of such discretion, notwithstanding any recommendation of the Advisory Board. Manager and PDS shall, however, take such
