Utilization Management (UM. Director who is an Ohio-licensed registered nurse or a physician with a current unencumbered license through the Ohio State Medical Board preferably with a certification as a Certified Professional in Health Care Quality (CPHQ) by the National Association for Health Care Quality (NAHQ) and/or Certified in Health Care Quality and Management (CHCQM) by the American Board of Quality Assurance and Utilization Review Providers. The UM Director is responsible for overseeing the day-to-day operational activities of the Utilization Management Program in accordance with state guidelines. The UM Director shall have experience in the activities of utilization management as specified in 42 CFR 438.210. Primary functions of the Director of Utilization Management position are to ensure:
Utilization Management (UM a. The County must have documented policies and procedures for all UM activities that involve determining medical necessity, and the approval or denial of mental health services. Qualified mental health professionals must be involved in any decision- making that requires clinical judgment. The decision to deny, reduce or authorize a service that is less than requested must be made by a health professional with appropriate clinical expertise in treating the affected member’s condition(s). The County may not deny coverage, penalize providers, or give incentives or payments to providers or enrollees that are intended to reward inappropriate restrictions on care or result in the under-utilization of services. Criteria used to determine medical necessity and appropriateness must be communicated to providers. The criteria for determining medical necessity may not be more stringent than DHS 101.03 (96m), Wis. Adm. Code.
Utilization Management (UM. 1. The HMO must have documented policies and procedures for all UM activities that involve determining medical necessity, and the approval or denial of medical services. Qualified medical professionals must be involved in any decision-making that requires clinical judgment. The decision to deny, reduce or authorize a service that is less than requested must be made by a health professional with appropriate clinical expertise in treating the affected enrollee’s condition(s). Criteria used to determine medical necessity and appropriateness must be communicated to providers. The criteria for determining medical necessity may not be more stringent than HFS 101.03 (96m) Wis. Adm. Code.
Utilization Management (UM. A strategy designed to ensure that health care expenditures are restricted to those that are needed and appropriate by reviewing CDCR/CCHCS patient and/or DJJ youth medical records through the application of defined criteria and/or expert opinion. It assesses the efficiency of the health care process and the appropriateness of decision making related to the site of care, its frequency and its duration, through prospective, concurrent, and retrospective utilization reviews.
Utilization Management (UM. A. CDCR/CCHCS reserves the right to inspect, monitor, and perform utilization reviews prospectively, concurrently, or retrospectively, regarding the courses of medical treatment or hospitalization provided to CDCR/CCHCS patients and/or DJJ youth when performed by Contractor and/or providers. CDCR/CCHCS may delegate this right to another State agency or party. Such reviews shall be undertaken to determine whether the course of treatment or services had prior authorization, were medically necessary and performed in accordance with CCHCS Medical Standards of Care. CCHCS Medical Standards of Care means InterQual® Care Planning Criteria, published by McKesson Health Solutions, LLC, except to the extent they conflict with the Inmate Medical Services Policies and Procedures (IMSP&P), except to the extent the InterQual® criteria or the IMSP&Ps conflict with Articles 8 and 9, of Subchapter 4, of Chapter 1, of Division 3, of Title 15 of the California Code of Regulations. Requests for InterQual® criteria should be directed to xx@xxxx.xx.xxx and the IMSP&Ps are available at xxxx://xxx.xxxxx.xx.xxx/imspp.aspx.
Utilization Management (UM. As subject to and further defined by the County/DHCS LIHP Contract, including without limitation Attachment 5 of Exhibit A and as further specified in Attachment A, Section IV(2) below:
Utilization Management (UM. Provider shall comply with Partners’ UM programs, quality management programs, and provider sanctions programs, provided that such programs shall not override the professional or ethical responsibility of Provider or interfere with Provider's ability to provide information or assistance to Provider’s patients. (Attachment F.a.xvii.p.319)
Utilization Management (UM. Refers to the process to evaluate the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities. Utilization Management is inclusive of utilization review and service authorization. Utilization Review (UR) – Evaluation of the clinical necessity, appropriateness, efficacy, or efficiency of core health care benefits and services, procedures or settings, and ambulatory review, prospective review, concurrent review, second opinions, care management, discharge planning, or retrospective review.
Utilization Management (UM. The CONTRACTOR shall:
Utilization Management (UM. The process of evaluating necessity, appropriateness and efficiency of healthcare services through the revision of information about hospital, service or procedure from patients and/or providers to determine whether it meets established guidelines and criteria approved by the ADMINISTRATION, the HCO and TPA as applicable.
