Quality Improvement and Utilization Management. A. BCBSTX Responsibilities. BCBSTX shall conduct peer review, quality improvement and the UM Program in accordance with Applicable Laws. BCBSTX’s UM Program may include the establishment of advisory review panels to conduct quality of care and utilization review activities in accordance with Applicable Laws. All BCBSTX quality improvement and UM forms, records and other information shall remain the property of BCBSTX and shall remain confidential.
Quality Improvement and Utilization Management. Provider shall cooperate and comply with HMSA's medical policies and quality assurance, performance improvement and medical management programs. Such cooperation and compliance shall include, but not be limited to, providing to HMSA, and to CMS, if requested, such data as HMSA may deem necessary to implement HMSA’s quality improvement program and HMSA’s reporting requirements to CMS; participating in CMS and HHS quality improvement initiatives (including medical care evaluation studies, clinical practice guidelines, peer review, practice pattern analysis based on Claims data, audit of medical records, problem identification and resolution, and priority-setting); and, as requested by HMSA, consulting with HMSA regarding HMSA’s medical policy, quality improvement and medical management policies and the development of practice and utilization management guidelines. Provider agrees to work in good faith with HMSA to implement corrective actions recommended by an HMSA review committee composed of practicing physicians, and to permit such a committee to monitor and evaluate such corrective actions. Provider’s right to appeal a corrective action decision is set forth in Section 8.1(a) of this Agreement. Furthermore, with respect to the provision of Covered Services to HMSA Medicare Cost Plan Members, Provider shall comply with requirements for Quality Improvement Organization (“QIO”) review of such services as set forth in 42 C.F.R. 417.478(a), and shall furnish to the QIO requested on-site access to or copies of patient care records and other pertinent data, and permit the QIO or its subcontractor to examine Provider’s operations and records necessary for the QIO to carry out its functions. With respect to Provider’s participation in any HMSA MA-PD Plan, Provider shall cooperate, participate and support quality assurance, cost, utilization management and medication therapy management programs, and support e-prescribing in accordance with 42 C.F.R. Part 423, Subpart D. Provider shall also participate in and comply with HMSA’s utilization management programs and requirements as described in the Provider E-Library and Plan Documents, and/or as required by regulatory and accrediting agencies. Payments may be reduced or denied if Provider fails to satisfy a utilization management requirement and an HMSA Medical Director determines that the service does not meet Payment Determination Criteria set forth in Section 4.2 of this Agreement. Provider shall not attempt to co...
Quality Improvement and Utilization Management. Group and CI Participating Physicians shall abide by and comply with any quality improvement, safety, disease management and utilization management programs, processes and procedures and the related clinical protocol standards and other requirements of the Clinical Integration Program. All such plans and requirements of the Clinical Integration Program, as now in effect and as may be amended from time to time, are incorporated into this Addendum by reference. These plans and requirements may differ significantly from those quality improvement or utilization management programs currently in place under the Agreement. Physician shall be notified in advance of any such changes or revisions.
Quality Improvement and Utilization Management. Provider agrees to cooperate with, participate in, and comply with the requirements of CareSource’s quality improvement and utilization management programs. Provider agrees that CareSource may use Provider’s performance data for CareSource’s quality improvement activities. Upon reasonable notice and at reasonable hours, CareSource or its agents may inspect Provider’s premises and operations to ensure that such premises and operations are appropriate to meet Covered Persons’ needs and to comply with quality assurance guidelines. Provider shall notify CareSource within five (5) days of the initiation of any complaint, inquiry, investigation, or review with or by any licensing or regulatory authority, peer review organization, Provider committee, or other committee, organization or body which reviews quality of medical care if such action involves or is related to a Covered Person. Further, Provider shall notify CareSource within five (5) days after it has been determined that the basis for any such complaint, inquiry, investigation, or review is substantiated (an adverse outcome). Provider will assist CareSource in fulfilling CareSource’s legal obligations with respect to the collection and reporting of data including, but not limited to, HEDIS and STARs requirements.
Quality Improvement and Utilization Management. Provider agrees to cooperate with, participate in, and comply with the requirements of TrueCare’s quality improvement and utilization management programs. Provider agrees that TrueCare may use Provider’s performance data for TrueCare’s quality improvement activities. Upon reasonable notice and at reasonable hours, TrueCare or its agents may inspect Provider’s premises and operations to ensure that such premises and operations are appropriate to meet Covered Persons’ needs and to comply with quality assurance guidelines. Provider shall notify TrueCare within five (5) days of the initiation of any complaint, inquiry, investigation, or review with or by any licensing or regulatory authority, peer review organization, Provider committee, or other committee, organization or body which reviews quality of medical care if such action involves or is related to a Covered Person. Further, Provider shall notify TrueCare within five (5) days after it has been determined that the basis for any such complaint, inquiry, investigation, or review is substantiated (an adverse outcome). Provider will assist TrueCare in fulfilling TrueCare’s legal obligations with respect to the collection and reporting of data including, but not limited to, HEDIS and STARs requirements.
Quality Improvement and Utilization Management
