Utilization Management Program. To adopt and maintain a Utilization Management Program consistent with BLUE CROSS standards and approved by BLUE CROSS. This program will cover all Covered Medical Services provided or arranged by PARTICIPATING MEDICAL GROUP for Members. PARTICIPATING MEDICAL GROUP agrees to allow on-site review of Utilization Management Program by BLUE CROSS.
A. The Utilization Management Program shall:
(1) Include the development and implementation of appropriate recommendations.
(2) Include documentation of remedial procedures for instances of inappropriate or substandard services(s) and or failure to provide Medically Necessary Covered Medical Services.
(3) Assure that PARTICIPATING MEDICAL GROUP’s primary consideration is the quality of services rendered to Members.
(4) Assure that all services provided to Members are Medically Necessary.
(5) Work closely with CALIFORNIACARE Hospitals.
(6) Encompass inpatient, outpatient, and ancillary care.
(7) Utilize prospective, concurrent, and retrospective review.
(8) Assure that all adverse utilization review decisions are made by a licensed physician, and no denial of a requested service shall be made except by a licensed physician, experienced in the area being reviewed. Denial decisions shall be provided to Members in writing.
(9) Permit BLUE CROSS to have access to all PARTICIPATING MEDICAL GROUP Utilization Management data directly or indirectly relating to Members.
B. BLUE CROSS shall validate PARTICIPATING MEDICAL GROUP’s development and implementation of the Utilization Management Program through regular audit activities as follows:
(1) The CALIFORNIACARE Quality Management Department shall review PARTICIPATING MEDICAL GROUP’ Utilization Management Program on an annual basis through a scheduled on-site audit.
(2) The CALIFORNIACARE Quality Management Representative shall notify PARTICIPATING MEDICAL GROUP of any deficiencies or areas needing improvement.
(3) PARTICIPATING MEDICAL GROUP shall take corrective action to eliminate any deficiencies in areas needing improvement within a reasonable period of time.
(4) BLUE CROSS shall conduct follow-up reviews as necessary.
C. PARTICIPATING MEDICAL GROUP shall:
(1) Make available to BLUE CROSS summaries of all minutes and notes from any and all Utilization Management Committees and/or activities which relate to Members.
(2) Make available to BLUE CROSS upon request all composite Utilization Management data which include Members in the composite data set and provide such detail...
Utilization Management Program. The Contractor shall not require prior authorization for an emergency admission for psychiatric inpatient hospital services, whether the admission is voluntary or involuntary. (Cal. Code Regs., tit. 9, §§ 1820.200(d) and 1820.225). The Contractor that is the MHP of the beneficiary being admitted on an emergency basis shall approve a request for payment authorization if the beneficiary meets the criteria for medical necessity and the beneficiary, due to a mental disorder, is a current danger to self or others, or immediately unable to provide for, or utilize, food, shelter or clothing. (Cal Code Regs, tit. 9 §§ 1820.205 and 1820.
Utilization Management Program. A process of review of the medical necessity, appropriateness and efficiency of health care services, procedures, equipment, supplies, and facilities rendered to Members.
Utilization Management Program. The Contractor shall implement a Utilization Management (UM) Program that meets the requirements set forth in this section and that is documented in a plan as defined in KRS 304.17A- 600. The UM program, processes and timeframes shall be in accordance with 42 C.F.R. 456, 42 C.F.R. 431, 42 C.F.R. 438. If the Contractor utilizes a private review agent, as defined in KRS 304.17A-600, the agent shall comply with all applicable requirements of KRS 304.17A-600 to 304.17A-633, as applicable. The Medical Director and Behavioral Health Director shall supervise the UM Program and shall be accessible and available for consultation as needed. The Contractor shall implement innovative and effective Utilization Management processes to ensure a high quality, clinically appropriate yet highly efficient and cost-effective delivery system. The Contractor shall continually evaluate the cost and quality of medical services delivered by Providers. The Contractor shall apply objective and evidence-based criteria that take the individual Enrollee’s circumstances when determining the Medical Necessity of health care services. The Contractor shall have a written plan for the UM program that details the program structure and, if delegated, includes a clear definition of authority and accountability for all activities between the Contractor and entities to which the Contractor delegates UM activities. The UM Program and Review Plan shall comply with KRS 304.17A-600 and include the following information, at a minimum:
A. Scope of the program;
B. The processes and information sources used to determine service coverage;
C. List which services require PCP Referral; which services require Prior Authorization and how requests for initial and continuing services are processed;
D. Written policies and procedures to evaluate Medical Necessity, the criteria used, information sources, timeframes and the process used to review, approve, or deny the provision of services, as needed, including those specific to the EPSDT program;
E. Policies and procedures to evaluate discharge criteria, site of services, levels of care, triage decisions and cultural competence of care delivery;
F. Written policies and procedures for monitoring to ensure clinically appropriate overall continuity of care;
G. Written policies to ensure the coordination of services:
1. Between settings of care, including appropriate Discharge Planning for short-term and long-term hospital and institutional stays;
2. With the service...
Utilization Management Program. Provider shall cooperate and comply with and participate in any applicable utilization management programs established (or amended from time to time) by Local Initiative and by Health Plan and approved by DHCS and DMHC.
Utilization Management Program. Contractor shall develop, implement, and continuously update and improve, a Utilization Management (UM) program that ensures appropriate processes are used to review and approve the provision of Medically Necessary Covered Services. Contractor is responsible to ensure that the UM program includes:
A. Qualified staff responsible for the UM program.
B. The separation of medical decisions from fiscal and administrative management to assure those medical decisions will not be unduly influenced by fiscal and administrative management.
C. Contractor shall ensure that the UM program allows for a second opinion from a qualified health professional at no cost to the Member.
D. Established criteria for approving, modifying, deferring, or denying requested services. Contractor shall utilize evaluation criteria and standards to approve, modify, defer, or deny services. Contractor shall document the manner in which providers are involved in the development and or adoption of specific criteria used by the Contractor.
E. Contractor shall communicate to health care practitioners the procedures and services that require prior authorization and ensure that all contracting health care practitioners are aware of the procedures and timeframes necessary to obtain prior authorization for these services.
F. An established specialty referral system to track and monitor referrals requiring prior authorization through the Contractor. The system shall include authorized, denied, deferred, or modified referrals, and the timeliness of the referrals. This specialty referral system should include non-contracting providers. Contractor shall ensure that all contracting health care practitioners are aware of the referral processes and tracking procedures.
G. The integration of UM activities into the Quality Improvement System (QIS), including a process to integrate reports on review of the number and types of appeals, denials, deferrals, and modifications to the appropriate QIS staff. These activities shall be done in accordance with Health and Safety Code Section 1363.5 and Title 28, CCR, Section 1300.70(b)(2)(H) & (c).
Utilization Management Program. A process adopted by HMO for the review of the appropriateness and necessity of health care services rendered to Members.
Utilization Management Program. Contractor shall develop, implement, and continuously update and improve, a Utilization Management (UM) program that ensures appropriate processes are used to review and approve the provision of Medically Necessary Covered Services. Contractor is responsible to ensure that the UM program includes:
A. Qualified staff responsible for the UM program.
B. Contractor shall ensure that the UM program allows for a second opinion from a qualified health professional at no cost to the Enrollee.
C. Established criteria for approving, modifying, deferring, or denying requested services. Contractor shall utilize evaluation criteria and standards to approve, modify, defer, or deny services. Contractor shall document the manner in which providers are involved in the development and or adoption of specific criteria used by the Contractor.
D. Contractor shall communicate to health care practitioners the procedures and services that require prior authorization and ensure that all contracting providers are aware of the procedures and timeframes necessary to obtain prior authorization for these services.
E. The integration of UM activities into the Quality Improvement System (QIS), described in Exhibit A, Attachment 4 Quality Improvement System, including a process to integrate reports on review of the number and types of appeals, denials, deferrals, and modifications to the appropriate QIS staff.
Utilization Management Program. In rendering services to Beneficiaries of this Product, Physician will comply with Payor’s Utilization Management Program for this Product (“UM Program”) as set forth in the Policy and Procedure Manual. If, in the professional judgment of Physician, it is medically necessary, timely and appropriate to deliver health care services in a manner which differs from the UM Program, Physician will render health care services in a manner keeping with his/her best professional judgment irrespective of a Payor’s coverage decision.
Utilization Management Program. Provider shall cooperate and comply with and participate in any applicable utilization management programs established (or amended from time to time) by Blue Shield and approved by DHCS and DMHC.
