Common use of Utilization Management Plan Clause in Contracts

Utilization Management Plan. Prior to the execution of this Agreement, and if utilization management functions are delegated to Group by Blue Shield, Group will provide Blue Shield with a written Utilization Management Plan for the purpose of review and approval by Blue Shield. Group shall notify Blue Shield within thirty (30) days of any changes involving the rules, regulations, authorities and responsibilities for the Utilization Management Plan, which shall be subject to reasonable approval thereof by Blue Shield. The Utilization Management Plan shall include procedures approved by Blue Shield to identify, assess, establish, and implement a treatment plan for Members who have complex or serious medical conditions, and for direct access of Members to services as mandated by the BBA and related regulations. Group agrees to comply with Blue Shield’s Medical Policies. All Group denial letters shall be reviewed and approved by Blue Shield. Group agrees to cooperate with Blue Shield in furnishing the required reports identified in the Provider Manual.”

Utilization Management Plan. Prior to the execution of this Agreement, and if utilization management functions are delegated to Group by Blue Shield, Group will provide Blue Shield with a written Utilization Management Plan for the purpose of review and approval by Blue Shield. Group shall notify Blue Shield within thirty (30) days of any changes involving the rules, regulations, authorities and responsibilities for the Utilization Management Plan, which shall be subject to reasonable approval thereof by Blue Shield. The Utilization Management Plan shall include procedures approved by Blue Shield to identifyidentity, assess, establish, and implement a treatment plan for Members who have complex or serious medical conditions, and for direct access of Members to services as mandated by the BBA and related regulations. Group agrees to comply with Blue Shield’s Medical Policies. All Group denial letters shall be reviewed and approved by Blue Shield. Group agrees to cooperate with Blue Shield in furnishing the required reports identified in the Provider Manual.”