Utilization Management Requirements. 11.1.1 The Contractor’s Behavioral Health Medical Director will provide guidance, leadership and oversight of the Contractor’s Utilization Management (UM) program for Contracted Services used by Individuals. The following activities may be carried out in conjunction with the administrative staff or other clinical staff, but are the responsibility of the Behavioral Health Medical Director to oversee:
Utilization Management Requirements. Failure to meet the requirements of the Utilization Management Program may result in a reduction or denial of benefits even if the services are Medically Necessary. Prior authorization from CareFirst will be obtained by In-Network Providers located in the CareFirst service area. It is the Member's responsibility to obtain prior authorization when services are rendered outside of the CareFirst service area and for services rendered by Out-of-Network Non-Preferred Providers.
Utilization Management Requirements. Provider shall abide by clinically sound criteria. Provider shall seek authorization prior to service delivery and provide accurate and thorough information requested so that service provision is not unduly delayed or disrupted.
Utilization Management Requirements. Certain Covered Services are subject to review and approval under Utilization Management requirements established by the Plan. Section 1.16 and Section 1.17 of this Agreement further describe Evergreen’s Utilization Management program and Covered Services subject to prior authorization.
Utilization Management Requirements. A. Generally Except for Urgent Care, Emergency Services and follow−up care after emergency surgery, it is the provider’s responsibility to obtain prior authorization for all services that require prior authorization. Subsection 1.16F below lists those services. Through Utilization Management, Evergreen will: (i) review Member care and evaluate requests for approval of coverage in order to determine the Medical Necessity for the services; (ii) review the appropriateness of the hospital or facility requested; and (iii) determine the approved length of confinement or course of treatment in accordance with Evergreen established criteria. In addition, Utilization Management may include additional aspects such as prior authorization, second surgical opinion and/or pre−admission testing requirements, concurrent review, discharge planning, disease management and case management.
Utilization Management Requirements. Except for Urgent Care, Emergency Services and follow−up care after emergency surgery, it is the Member’s responsibility to obtain prior authorization for all services that require prior authorization. Members must make arrangements with Evergreen to obtain Utilization Management authorizations and approvals required for Covered Services received from both Plan Providers and Non−Plan Providers. Refer to Sections 1.15 and 1.16 of the Description of Covered Services (Attachment A) Agreement for a full description of Utilization Management requirements and for Covered Services that require prior authorization.
Utilization Management Requirements. 1.2.9.1 Contractor shall accept the IM+CANS established by the CCSO and the Enrollee’s CFT, as applicable, as the IPoC for Enrollees who are N.B. class members.
Utilization Management Requirements. Provider agrees to ------------------------------------ participate in, cooperate with and comply with all decisions rendered in connection with Foundation's, an Affiliate's or a Payor's Utilization Management Program. The hospital shall submit indicator data relevant to its services to the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) Indicator Measurement System. The data will be submitted on a timely basis and meet the reasonable standards set by JCAHO for completeness and reliability. Provider also agrees to provide such other records and information as may be required or requested under such Utilization Management Program. Provider shall notify Foundation's Health Care Services Department in the event of any inpatient admission, in addition to any notification required by the Beneficiary's Capitated Medical Group/IPA.
Utilization Management Requirements. RPO agrees and shall use commercially reasonable efforts to cause all RPO Providers to participate in, cooperate with and comply with all decisions rendered in connection with Texas HealthSpring's, an Affiliate's, or a Payor's Utilization Management Program. RPO also agrees and shall use commercially reasonable efforts to cause all RPO Providers to provide such records and other information as may be required or requested under such Utilization Management Program. RPO shall accept delegation of and perform utilization management with respect to Contracted Services provided under this Agreement in accordance with the Delegated Services Agreement. RPO shall perform such utilization management in accordance with the performance standards and criteria of Texas HealthSpring or a Payor. Texas HealthSpring shall have the right to audit RPO's performance of utilization management as solely determined by Texas HealthSpring and to reassume the obligation for utilization management in the event Texas HealthSpring determines that RPO either does not have the capacity to perform, or is not effectively performing utilization management.
Utilization Management Requirements. Whether announced or unannounced, Provider agrees to cooperate with, participate in, and abide by internal or external quality assessment reviews, Member Appeal Procedures, Utilization Management Program procedures, and Quality Management Program procedures established by the Plan, and to follow practice guidelines as described in the Provider Manual and other Plan notices.
