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.
Appears in 4 contracts
Samples: Provider Agreement (Wellcare Health Plans, Inc.), CFC Provider Agreement (Wellcare Health Plans, Inc.), Wellcare Health Plans, Inc.
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.
Appears in 2 contracts
Samples: Provider Agreement (Molina Healthcare Inc), Provider Agreement (Molina Healthcare Inc)
