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. 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 provider in or out-of-network. Typical cost-sharing will apply. Technology Assessment Committee We have a process to continuously evaluate evolving medical technologies, which include medical procedures, drugs and devices. In-network Practitioners from our PPO Network and the community along with other clinical staff are responsible for this process and are known as the Technology Assessment Committee. The Technology Assessment Committee evaluates new technologies and/or new applications of existing technologies, determines the value of the new technology, and recommends whether the technology should be a specified Covered Benefit of your Plan. Factors to be considered include safety, comparison to existing drugs, procedures and technology, cost and effectiveness of the new technology, and clinical skills and training of those proposing to provide the new technology. Transition of Care If we terminate or suspend any contract with an In-network Practitioner/Provider from which you are currently receiving care, we will notify you, in writing, within 30 days. We will assist you in locating and transferring to another similarly qualified In-network Practitioner/Provider, if available, for continued In-network benefits. You may elect to continue to receive care from this Out-of-network Practitioner/Provider; however, we will only reimburse for such services in accordance with applicable Out-of-network benefit level, if any, and then subject to Medicare Allowable Charges except when you wish to continue an ongoing course of treatment with the provider for a transitional period. This period shall...
