Quality; Utilization Management. Pursuant to any applicable provider manual/administrative guide and related protocols, or as elsewhere specified under the Agreement, Provider agrees to cooperate with Health Plan and/or Subcontractor’s quality assessment, performance improvement and utilization review and management activities. This shall include, but not be limited to, participation in any internal and external quality assurance, utilization review, peer review, and grievance procedures established by Health Plan and/or Subcontractor or as required under the State Contract to ensure that Covered Persons have due process for their complaints, grievances, appeals, fair hearings or requests for external review of adverse decisions made by Health Plan and/or Subcontractor or Provider. Provider shall adhere to the quality assurance and utilization review standards of the applicable State Program and shall monitor quality and initiate corrective action to improve quality consistent with the generally accepted level of care. Provider shall develop, maintain and use a system for prior authorization and utilization review that is consistent with Department’s rules and policies. Provider shall comply with 42 CFR Part 456, as specified in AMPM Chapter 900 and 1000.
Appears in 2 contracts
Samples: Arizona Acc Medicaid and Chip Program Regulatory Requirements Appendix, Downstream Provider Agreement
Quality; Utilization Management. Pursuant to any applicable provider manual/administrative guide and related protocols, or as elsewhere specified under the Agreement, Provider agrees to cooperate with Health Plan Plan’s and/or Subcontractor’s quality assessment, performance improvement and utilization review and management activities. This shall include, but not be limited to, participation in any internal and external quality assurance, utilization review, peer review, and grievance procedures established by Health Plan and/or Subcontractor Subcontractor, or as required under the State Contract Contract, to ensure that Covered Persons have due process for their complaints, grievances, appeals, fair hearings or requests for external review of adverse decisions made by Health Plan and/or Subcontractor Plan, Subcontractor, or Provider. Provider shall adhere to the quality assurance and utilization review standards of the applicable State Program and shall monitor quality and initiate corrective action to improve quality consistent with the generally accepted level of care. Provider shall develop, maintain and use a system for prior authorization and utilization review that is consistent with Department’s rules and policies. Provider shall comply with 42 CFR Part 456, as specified in AMPM Chapter 900 and 1000.
Appears in 1 contract
Samples: Arizona Medicaid and Chip Program Regulatory Requirements Appendix
Quality; Utilization Management. Pursuant to any applicable provider manual/administrative guide and related protocols, or as elsewhere specified under the Agreement, Provider agrees to cooperate with Health Plan Plan’s and/or Subcontractor’s quality assessment, performance improvement and utilization review and management activities. This shall include, but not be limited to, participation in any internal and external quality assurance, utilization review, peer review, and grievance procedures established by Health Plan and/or Subcontractor Subcontractor, or as required under the State Contract Contract, to ensure that Covered Persons have due process for their complaints, grievances, appeals, fair hearings or requests for external review of adverse decisions made by Health Plan and/or Subcontractor Plan, Subcontractor, or Provider. Provider shall adhere to the quality assurance and utilization review standards of the applicable State Program and shall monitor quality and initiate corrective action to improve quality consistent with the generally accepted level of care. Provider shall develop, maintain and use a system for prior authorization and utilization review that is consistent with Department’s rules and policies. Provider shall comply with 42 CFR Part 456, as specified in AMPM Chapter 900 and 1000.
Appears in 1 contract
Samples: Arizona Medicaid Developmentally Disabled Program Regulatory Requirements Appendix
