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.
Utilization Management Program. E. 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. 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:
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:
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. A process adopted by HMO for the review of the appropriateness and necessity of health care services rendered to Members.
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.
Utilization Management Program. 9.1.1. The Contractor shall have and maintain a Utilization Management Program (UMP) for the services it furnishes its enrollees.
Utilization Management Program. Benefits due to Insureds are subject to the following Utilization Management: Prior Authorization Review is intended to confirm the Medical Necessity and medical appropriateness of a setting, service, treatment, supply, device, or prescription drug. If a setting, service, treatment, supply, device, or prescription drug is listed below, Prior Authorization Review must be obtained before incurring any claims for that setting, service, treatment, supply, device, or prescription drug. You are responsible for obtaining Prior Authorization Review when required. You can obtain Prior Authorization Review by contacting us at: Company: Seton Health Plan, dba: Dell Children’s Health Plan Address: 0000 Xxxxxxxxx Xx., Suite #305 Austin, TX 78723 Phone: 0-000-000-0000 (TTY: 000-000-0000) Fax: 000-000-0000 Email: XXX-Xxxxxxxxxxxxx@xxxxxxxxx.xxx Prior authorization is not a guarantee that benefits will be payable. All benefits payable are subject to all of the terms, conditions, provisions, exclusions, and limitations of the Policy. The following settings, services, treatments, supplies, devices, or prescription drugs require Prior Authorization Review: ▪ Inpatient admissions (including acute care, long term acute care- behavioral health and/or Substance Abuse rehabilitation, residential treatment and partial hospitalization; skilled nursing facility). ▪ Emergency admissions within 48 hours following admission ▪ High Risk Maternity (routine that exceeds federal requirements) ▪ Outpatient Surgical Procedures ▪ Oral Pharynx Procedures ▪ Spinal Procedures ▪ Diagnostic Radiology ▪ Therapeutic Radiology ▪ Neuropsychological Testing ▪ Orthotics and Prosthetics ▪ Durable Medical Equipment (including DME items more than $1000) ▪ Hearing (EAR) devices ▪ Transplants (other than Corneal Transplants) ▪ Home Health Care ▪ Home Infusion Therapy ▪ Rehabilitative and Habilitative Outpatient Therapy ▪ Injectable Medications (administered by a healthcare provider) ▪ Genetic Testing ▪ Potential Experimental or Investigational treatment, testing or procedures ▪ Biomarker Testing *This list of services requiring Prior Authorization Review is not all inclusive. Failure to utilize or abide by the decisions of the Utilization Management Program will result in the denial of the claim for failing to prior authorize in advance of the proposed procedure or admission. However, if the covered service was found to be Medically Necessary, we will pay up to 50% of the allowable charge. Prior Authorizatio...
