Common use of Utilization Management Program Clause in Contracts

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 as is available regarding those Members. (3) Provide the CALIFORNIACARE Medical Director (or the Medical Director’s clinical designee) with a schedule designating the time and place of all Utilization Management Committee meetings that relate to Members, in order that he or she shall, in the Medical Director’s discretion, attend. The CALIFORNIACARE Medical Director shall notify the PARTICIPATING MEDICAL GROUP in advance of his or her attendance and shall not be excluded from any deliberation on activities related to Members.

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. 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 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, 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’ 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 shallShall: (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 as is available regarding those Members. (3) Provide the CALIFORNIACARE Medical Director (or the Medical Director’s clinical designee) with a schedule designating the time and place of all Utilization Management Committee meetings that relate to Members, in order that he or she shall, in the Medical Director’s discretion, attend. The CALIFORNIACARE Medical Director shall notify the PARTICIPATING MEDICAL GROUP in advance of his or her attendance and shall not be excluded from any deliberation on activities related to Members.

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 review(s) 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 as described in the Operations Manual 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 AIM 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 in accordance with the Operations Manual and as follows: (1) The CALIFORNIACARE BLUE CROSS Quality Management Department shall review PARTICIPATING MEDICAL GROUP’ Utilization Management Program on an annual basis through a scheduled on-site audit. (2) The CALIFORNIACARE AIM 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 as is available regarding those Members. (3) Provide the CALIFORNIACARE BLUE CROSS Medical Director (or the Medical Director’s clinical designee) with a schedule designating the time and place of all Utilization Management Committee meetings that relate to Members, in order that he or she shall, in the Medical Director’s discretion, attend. The CALIFORNIACARE BLUE CROSS Medical Director shall notify the PARTICIPATING MEDICAL GROUP in advance of his or her attendance and shall not be excluded from any deliberation on activities related to Members.

Utilization Management Program. To adopt and maintain a Utilization Management Program consistent with BLUE CROSS standards and approved by BLUE CROSS. 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 review(s) 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 as described in the Operations Manual 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 in accordance with the Operations Manual and 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 as is available regarding those Members. (3) Provide the CALIFORNIACARE Medical Director (or the Medical Director’s clinical designee) with a schedule designating the time and place of all Utilization Management Committee meetings that relate to Members, in order that he or she shall, shall in the Medical Director’s discretion, attend. The CALIFORNIACARE Medical Director shall notify the PARTICIPATING MEDICAL GROUP in advance of his or her attendance and shall not be excluded from any deliberation on activities related to Members.

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 review(s) 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 as described in the Operations Manual 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 in accordance with the Operations Manual and 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 as is available regarding those Members. (3) Provide the CALIFORNIACARE Medical Director (or the Medical Director’s clinical designee) with a schedule designating the time and place of all Utilization Management Committee meetings that relate to Members, in order that he or she shall, in the Medical Director’s discretion, attend. The CALIFORNIACARE Medical Director shall notify the PARTICIPATING MEDICAL GROUP in advance of his or her attendance and shall not be excluded from any deliberation on activities related to Members. (4) Comply with all applicable laws and regulations concerning utilization management criteria and processes, including, without limitation, California Health and Safety Code Sections 1363.5 and 1367.01.

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, outpatient and ancillary ancilary care. (7) Utilize prospective, concurrent, 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 as is available regarding those Members. (3) Provide the CALIFORNIACARE Medical Director (or the Medical Director’s clinical designee) with a schedule designating the time and place of all Utilization Management Committee meetings that relate to Members, in order that he or she shall, in the Medical Director’s discretion, attend. The CALIFORNIACARE Medical Director shall notify the PARTICIPATING MEDICAL GROUP in advance of his or her attendance and shall not be excluded from any deliberation on activities related to Members.

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 '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 '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 as is available regarding those Members. (3) Provide the CALIFORNIACARE Medical Director (or the Medical Director’s clinical designee) with a schedule designating the time and place of all Utilization Management Committee meetings that relate to Members, in order that he or she shall, in the Medical Director’s discretion, attend. The CALIFORNIACARE Medical Director shall notify the PARTICIPATING MEDICAL GROUP in advance of his or her attendance and shall not be excluded from any deliberation on activities related to Members.