Utilization Management and Quality. We may review medical records, claims, and requests for Covered Services to establish that the services are/were Medically Necessary, delivered in the appropriate setting, consistent with the condition reported and with generally accepted standards of medical and surgical practice in the area where performed and according to the findings and opinions of our professional medical consultants. Utilization management decisions are based only on appropriateness of care and service. We do not reward Practitioners or other Healthcare Professionals conducting Utilization Review for denying coverage or services and we do not offer incentives to encourage underutilization. Members may seek a second opinion when questions arise as to the medical appropriateness of a diagnosis or the appropriateness of medical and/or surgical services. Members may seek the second opinion from any in-network provider. If you’d like to request a second opinion from an out-of-network provider, Presbyterian will assist you in making the arrangements. Typical cost- sharing will apply. If you’d like to request a second opinion from an out-of-network provider, please call the Presbyterian Customer Service Center Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000 and tell them you’d like to request a second opinion from an out-of-network provider. PCSC staff will submit the request to Utilization Management on your behalf.
Utilization Management and Quality. provided only if the provider agrees to accept reimbursement from Presbyterian at the rates applicable prior to the start of the transitional period as payment in full. Additionally, the provider must also agree to adhere to Presbyterian’s quality assurance requirements, to provide necessary medical information related to such care, and to follow Presbyterian’s policies and procedures, including but not limited to procedures regarding referrals, pre-authorization and treatment planning approved by Presbyterian. Prior Authorization
Utilization Management and Quality. We may review medical records, claims, and requests for Covered Services to establish that the services are/were Medically Necessary, delivered in the appropriate setting, consistent with the condition reported and with generally accepted standards of medical and surgical practice in the area where performed and according to the findings and opinions of our professional medical consultants. The review will also be in accordance with applicable, generally accepted principles and practices of good medical care, practice guidelines developed by the federal government or national or professional medical societies, boards or associations, or applicable clinical protocols or practice guidelines developed by the health insurer consistent with federal, national and professional practice guidelines, which shall apply to the diagnosis, direct care and treatment of a physical or behavioral health condition, illness, injury or disease pursuant to 59A-22B-2J NMSA. Utilization management decisions are based only on appropriateness of care and service. We do not reward Practitioners or other Healthcare Professionals conducting Utilization Review for denying coverage or services and we do not offer incentives to encourage underutilization. Members may seek a second opinion when questions arise as to the medical appropriateness of a diagnosis or the appropriateness of medical and/or surgical services. Members may seek the second opinion from any in-network provider. If you’d like to request a second opinion from an out-of-network provider, Presbyterian will assist you in making the arrangements. Typical Cost Sharing will apply. If you’d like to request a second opinion from an out-of-network provider, please call the Presbyterian Customer Service Center Monday through Friday from 7 a.m. to 6 p.m. at (000) 000-0000 or 0-000-000-0000 and tell them you’d like to request a second opinion from an out-of-network provider. PCSC staff will submit the request to Utilization Management on your behalf.
