Utilization Management. Contractor shall maintain a utilization management program that complies with applicable laws, rules and regulations, including Health and Safety Code § 1367.01 and other requirements established by the applicable State Regulators responsible for oversight of Contractor.
Utilization Management. Case management means a care management plan developed for a Member whose diagnosis requires timely coordination. All benefits, including travel and lodging, are limited to Covered Services that are Medically Necessary and set forth in the EOC. KFHPWA may review a Member's medical records for the purpose of verifying delivery and coverage of services and items. Based on a prospective, concurrent or retrospective review, KFHPWA may deny coverage if, in its determination, such services are not Medically Necessary. Such determination shall be based on established clinical criteria and may require Preauthorization. KFHPWA will not deny coverage retroactively for services with Preauthorization and which have already been provided to the Member except in the case of an intentional misrepresentation of a material fact by the patient, Member, or provider of services, or if coverage was obtained based on inaccurate, false, or misleading information provided on the enrollment application, or for nonpayment of premiums.
Utilization Management. All benefits are limited to Covered Services that are Medically Necessary and set forth in the Agreement. KFHPWA may review a Member's medical records for the purpose of verifying delivery and coverage of services and items. Based on a prospective, concurrent or retrospective review, KFHPWA may deny coverage if, in its determination, such services are not Medically Necessary. Such determination shall be based on established clinical criteria. KFHPWA will not deny coverage retroactively for services with Preauthorization and which have already been provided to the Member except in the case of an intentional misrepresentation of a material fact by the patient, Member, or provider of services, or if coverage under this Agreement was obtained based on inaccurate, false, or misleading information provided on the enrollment application; or for nonpayment of premiums.
Utilization Management. 2.1 The contractor shall establish a Medical Management (MM)/UM Plan for care received by TRICARE beneficiaries.
2.1.1 The contractor’s MM/UM Plan shall recognize that the Military Treatment Facility (MTF) Primary Care Manager (PCM) retains clinical oversight for TOP Prime enrollees. As such, the enrolling MTF will determine medical and psychological necessity and issue all referrals for TOP Prime enrollees, and provide UM and all case management services for the MTF-enrolled population. The contractor shall ensure that MTF-issued referrals and appropriate authorizations are entered into all applicable contractor systems to ensure accurate, timely customer service and claims adjudication. The contractor shall perform certain UM activities to assist the MTF with the medical management of TOP Prime inpatients as described in paragraph 8.0. The contractor shall provide notification to the MTF Commander Manager or designee whenever an MTF enrollee is admitted to an inpatient facility (including mental health admissions), regardless of location. Note: Newborns/adoptees who are deemed enrolled in TOP Prime (based on the sponsor’s MTF enrollment) shall receive clinical oversight from the MTF.
2.1.2 The contractor shall determine medical and psychological necessity, conduct covered benefit review, and issue authorizations for specialty care for TOP Prime Remote enrollees and all Service members who are on Temporary Duty/Temporary Additional Duty (TDY/TAD), in an authorized leave status, or deployed/deployed on liberty in a remote overseas location. The contractor shall provide notification of cases to the appropriate TRICARE Area Office (TAO) for reviews involving remote Service member requests for specialty care, and whenever hospital admissions have occurred for any beneficiary not enrolled to a TOP MTF (including mental health admissions), regardless of location. Note: Newborns/adoptees who are deemed enrolled in TOP Prime (based on the sponsor’s TOP Prime Remote enrollment) shall receive clinical oversight from the TOP contractor.
2.1.3 The contractor shall review and authorize urgent specialty care for beneficiaries enrolled to a stateside contractor who are traveling outside of the 50 U.S. and the District of Columbia.
2.2 The MM/UM Plan shall recognize that purchased care sector network providers (except for TOP Partnership Providers) are the responsibility of the TOP contractor and the contractor shall ensure that any adverse finding related to purchased ...
Utilization Management. The process of evaluating the necessity, appropriateness and efficiency of health care services against established guidelines and criteria.
Utilization Management. State law requires that health plans disclose to Members and health plan providers the process used to authorize or deny health care services under the plan. Blue Shield has completed documentation of this process as required under Section 1363.5 of the California Health and Safety Code. The document describing Blue Shield’s Utilization Management Program is available online at xxx.xxxxxxxxxxxx.xxx or Members may call the Customer Service Department at the number provided on the back page of this Evidence of Coverage to request a copy.
Utilization Management. Pre-service, concurrent or retrospective review which determines the Medical Necessity of hospital and skilled nursing facility admissions and selected Health Care Services provided on an outpatient basis.
Utilization Management. A. The Contractor shall operate a Utilization Management Program that is responsible for assuring that beneficiaries have appropriate access to specialty mental health services as required in California Code of Regulations, title 9, section 1810.440(b)(1)-(3).
B. The Utilization Management Program shall evaluate medical necessity, appropriateness and efficiency of services provided to Medi-Cal beneficiaries prospectively or retrospectively.
C. Compensation to individuals or entities that conduct utilization management activities must not be structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any beneficiary. (42 C.F.R. § 438.210(e).)
D. The Contractor may place appropriate limits on a service based on criteria applied under the State Plan, such as medical necessity and for the purpose of utilization control, provided that the services furnished are sufficient in amount, duration or scope to reasonably achieve the purpose for which the services are furnished. (42 C.F.R. § 438.210(a)(4)(i), (ii)(A).)
Utilization Management. (a) The Network Service Provider shall develop and implement utilization management strategies that shall, at minimum, address the following areas:
a. Delivery of quality, clinically necessary services to eligible individuals in a timely fashion;
b. Improvement of clinical outcomes;
c. Guidelines, standards, and criteria set by regulatory and accrediting agencies are adhered to, as appropriate, for the client population;
d. Clinical evidence is used to make utilization management decisions, taking into account the local SOC and the individual’s circumstances; and
e. The utilization management strategies are integrated with the Network Service Provider’s Continuous Quality Improvement (CQI) activities.
Utilization Management. Providers shall cooperate and participate in Health Plan’s utilization review and case management programs. Health Plan’s utilization review/case management programs may include provisions for (a) verification of eligibility and prior authorization for Covered Services, (b) concurrent and retrospective reviews, (c) requirements regarding referrals to third party Participating Providers, and (d) corrective action plans.
