Common use of Utilization Management Program Clause in Contracts

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. 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. Compensation of staff or Subcontractors that conduct UM activities shall not be structured to provide incentives to deny, limit, or discontinue Medically Necessary services. 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 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 providersProviders. 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 appealsAppeals, denials, deferrals, and modifications to the appropriate QIS staff. H. Contractor shall ensure its UM program timelines and processes do not impose Quantitative Treatment Limitations (QTL), or Non-Quantitative Treatment Limitations (NQTL) more stringently on covered mental health and substance use disorder services than are imposed on medical/surgical services in accordance with the parity in mental health and substance use disorder requirements in 42 CFR 438.900 et seq., to its timelines and processes. I. Contractor shall make its UM or utilization review policies and procedures available to Members and Providers. These policies and procedures shall cover how Contractor, Subcontractors, or any contracted entity, authorize, modify, delay, or deny health care services via Prior Authorization, concurrent authorization, or retrospective authorization, under the benefits provided by Contractor. 1) Contractor shall ensure that policies and procedures for authorization decisions are based on the Medical Necessity of a requested health care service, and are consistent with criteria or guidelines supported by sound clinical principles. 2) Contractor shall ensure the policies, processes, strategies, evidentiary standards, and other factors used for UM or utilization review are consistently applied to medical/surgical, mental health, and substance use disorder services and benefits. 3) Contractor shall notify contracting health care Providers, as well as Members and Potential Enrollees upon request, of all services that require Prior Authorization, concurrent authorization, or retrospective authorization, and ensure that all contracting health care Providers are aware of the procedures and timeframes necessary to obtain authorization for these services These activities shall be done in accordance with Health and Safety Code Section Sections 1363.5 and 1367.01 and Title 28, CCR, Section 1300.70(b)(2)(H) & (c).

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. Compensation of staff or Subcontractors that conduct UM activities shall not be structured to provide incentives to deny, limit, or discontinue Medically Necessary services. 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 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 providersProviders . 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 appealsAppeals, 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).