Utilization Management Programs Sample Clauses

Utilization Management Programs. The MCP shall implement clearly defined structures and processes to maximize the effectiveness of the care provided to members pursuant to OAC rule 5160-26-03.1.
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Utilization Management Programs. In accordance with Sections 2.4 and 2.8 of the Three-Way, and OAC rules 5160-58-01.1 and 5160-26-03.1, the MCOP shall implement utilization management programs with clearly defined structures and processes to maximize the effectiveness of the care provided to dual benefits and Medicaid only members. Pursuant to the criteria in ORC Section 5160.34, the MCOP is prohibited from retroactively denying a prior authorization (PA) request as a utilization management strategy. When performing a pre-payment review of a claim the MCOP may not deny the claim due to medical necessity when the service was prior authorized. In addition, the MCOP shall permit the retrospective review of a claim submitted for a service where PA was required, but not obtained, pursuant to the criteria in ORC Section 5160.34. In accordance with ORC Section 5160.34, the MCOP is required to establish a streamlined provider appeal process relating to adverse PA determinations.
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Utilization Management Programs. General Provisions - Pursuant to OAC rule 5101:3-26-03.1(A)(7), MCPs must implement a utilization management (UM) program to maximize the effectiveness of the care provided to members and may develop other UM programs, subject to prior approval by ODJFS. For the purposes of this requirement, the specific UM programs which require ODJFS prior-approval are an MCP’s general pharmacy program, a controlled substances and member management program, and any other program designed by the MCP with the purpose of redirecting or restricting access to a particular service or service location.
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Utilization Management Programs. In accordance with Sections 2.4 and 2.8 of the Three-Way, and OAC rules 5160-58-01.1 and 5160-26-03.1, the MCOP shall implement utilization management programs with clearly defined structures and processes to maximize the effectiveness of the care provided to dual benefits and Medicaid only members. Pursuant to the criteria in ORC Section 5160.34, the MCOP is prohibited from retroactively denying a prior authorization (PA) request as a utilization management strategy. In addition, the MCOP shall permit the retrospective review of a claim submitted for a service where PA was required, but not obtained, pursuant to the criteria in ORC Section 5160.34. In accordance with ORC Section 5160.34, the MCOP is required to establish a streamlined provider appeal process relating to adverse PA determinations.
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Utilization Management Programs. The MCP shall implement clearly defined structures and processes to maximize the effectiveness of the care provided to members pursuant to OAC rule 5160-26-03.1. Pursuant to the criteria in ORC section 5160.34(C), the MCP is prohibited from retroactively denying a prior authorization (PA) request as a utilization management strategy. In addition, the MCP shall permit the retrospective review of a claim submitted for a service where PA was required, but not obtained, pursuant to the criteria in ORC section 5160.34(B)(9). Also ORC section 5160.34 requires the MCPs establish a streamlined provider appeal process relating to adverse PA determinations.
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Utilization Management Programs. General Provisions - Pursuant to OAC rule 5101:3-26-03.1(A)(7)(e), MCPs may implement utilization management programs, subject to prior approval by ODJFS. For the purposes of this requirement, utilization management programs are defined as programs designed by the MCP with the purpose of redirecting or restricting access to a particular service or service location. MCP care coordination and disease management activities which are designed to enhance the services provided to members with specific health care needs would not be considered utilization management programs nor would the designation of specific services requiring prior approval by the MCP or the member=s PCP. Emergency Department Diversion (EDD) – MCPs must provide access to services in a way that assures access to primary, specialist and urgent care in the most appropriate settings and that minimizes frequent, preventable utilization of emergency department (ED) services. OAC rule 5101:3-26-03.1(A)(7)(e) requires MCPs to implement the ODJFS-required emergency department diversion (EDD) program for frequent utilizers. Each MCP must establish an ED diversion (EDD) program with the goal of minimizing frequent ED utilization. The MCP’s EDD program must include the monitoring of ED utilization, identification of frequent ED utilizers, and targeted approaches designed to reduce avoidable ED utilization. MCP EDD programs must, at a minimum, address those ED visits which could have been prevented through improved education, access, quality or care management approaches. Although there is often an assumption that frequent ED visits are solely the result of a preference on the part of the member and education is therefore the standard remedy, it’s also important to ensure that a member’s frequent ED utilization is not due to problems such as their PCP’s lack of accessibility or failure to make appropriate specialist referrals. The MCP’s EDD diversion program must therefore also include the identification of providers who serve as PCPs for a substantial number of frequent ED utilizers and the implementation of corrective action with these providers as so indicated. This requirement does not replace the MCP’s responsibility to inform and educate all members regarding the appropriate use of the ED. In accordance with Appendix C, MCP Responsibilities, MCPs must submit to ODJFS by September 1, 2003, for review and approval, a written description of the MCP’s EDD program. Any subsequent changes to an approved ...
Sample 1
Utilization Management Programs. Contractor may develop programs under this Contract to ensure appropriate utilization. These programs shall be reviewed and approved by the Agency in advance of implementation.
Sample 1
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Utilization Management Programs. Managing the use of certain drugs is a key part of reining in the rising cost of care. Our utilization management (UM) programs offer the insight you need for greater control of why, how much and how often certain drugs are prescribed. Our UM programs give health care professionals guidance that supports appropriate drug use, keeping costs down for everyone, and improving member health and safety. We offer three primary types of UM programs, including step therapy, quantity limits, and prior authorizations described as follows:  Step therapy programs take a “step” approach to providing members a drug to help treat their condition. This means that members may first need to try a first-line drug before coverage is provided for a second-line drug. A first-line drug is usually a generic drug (or preferred brand if generics are not available) and represents a more cost-effective alternative for the member and Santa Xxxx County School Board.  Quantity limits programs promote safe and effective drug use and reduce waste by limiting certain prescriptions to a pre-determined quantity limit or duration.  Prior authorization programs prevent misuse, overuse or inappropriate use by requiring members to meet certain criteria before particular drugs are covered. While cost savings may be achieved through these programs, they are recommended to enhance drug safety and member health.  Medical Drug Review helps capture improvements in outcomes, safety and savings that result from changes in drug management under the medical benefit through our Comprehensive Clinical Review (CCR) program Generic Programs Our generic programs help increase utilization rates and build awareness of cost savings for generic products. We will work closely with Santa Xxxx County School Board on implementing the right benefit design and strategy for your business which may include member-focused communication strategies and reporting to identify and influence trends.  Outline and describe available formularies. Included pharmacy savings for each available formulary. BCBSF offers Santa Xxxx County School Board the BCBSF Medication Guide formulary, which provides members with broad access to safe, medically necessary products. The formulary identifies those agents that are preferred based on a comprehensive evaluation of each drug’s comparative clinical efficacy, safety, uniqueness, and cost. The evaluation is performed by BCBSF and Xxxxx's National Pharmacy and Therapeutics (P&T) Committee, co...
Sample 1

Related to Utilization Management Programs

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  • Construction Management Landlord or its Affiliate or agent shall supervise the Work, make disbursements required to be made to the contractor, and act as a liaison between the contractor and Tenant and coordinate the relationship between the Work, the Building and the Building’s Systems. In consideration for Landlord’s construction supervision services, Tenant shall pay to Landlord a construction supervision fee equal to three percent (3%) of Tenant’s Costs specified in Section 7.

  • Project Management Project Management Institute (PMI) certified project manager executing any or all of the following: • Development of Project Charter • Development of project plan and schedule • Coordination and scheduling of project activities across customer and functional areas • Consultation on operational and infrastructure requirements, standards and configurations • Facilitate project status meetings • Timely project status reporting • Address project issues with functional areas and management • Escalation of significant issues to customers and executive management • Manage project scope and deliverable requirements • Document changes to project scope and schedule • Facilitate and document project closeout

  • Investment Management Services (a) The Manager shall manage the Fund’s assets subject to and in accordance with the investment objectives and policies of the Fund and any directions which the Trust’s Board of Trustees may issue from time to time. In pursuance of the foregoing, the Manager shall make all determinations with respect to the investment of the Fund’s assets and the purchase and sale of its investment securities, and shall take such steps as may be necessary to implement the same. Such determinations and services shall include determining the manner in which any voting rights, rights to consent to corporate action and any other rights pertaining to the Fund’s investment securities shall be exercised. The Manager shall render or cause to be rendered regular reports to the Trust, at regular meetings of its Board of Trustees and at such other times as may be reasonably requested by the Trust’s Board of Trustees, of (i) the decisions made with respect to the investment of the Fund’s assets and the purchase and sale of its investment securities, (ii) the reasons for such decisions and (iii) the extent to which those decisions have been implemented.

  • Construction Management Fee The Construction Management Fee for the Project shall be either a ☒Lump Sum or ☐Not-To-Exceed Fee of Fifty-One Thousand, Four Hundred Fifty-Six Dollars and Twenty-Three Cents ($51,456.23). NOTE: Allowances will be on a Not-To-Exceed basis. All unused funds will be returned to the School District at the time of construction closeout. Fee will be paid only on cost of work for these items. Exhibit C- Project Assignment Page 2 of 4

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