Common use of Utilization Management Clause in Contracts

Utilization Management. All benefits are limited to Covered Services that are Medically Necessary and set forth in the Agreement. KFHPWA may review a Member's medical records for the purpose of verifying delivery and coverage of services and items. Based on a prospective, concurrent or retrospective review, KFHPWA may deny coverage if, in its determination, such services are not Medically Necessary. Such determination shall be based on established clinical criteria. KFHPWA will not deny coverage retroactively for services with Preauthorization and which have already been provided to the Member except in the case of an intentional misrepresentation of a material fact by the patient, Member, or provider of services, or if coverage under this Agreement was obtained based on inaccurate, false, or misleading information provided on the enrollment application; or for nonpayment of premiums.

Utilization Management. ‌ All benefits are limited to Covered Services that are Medically Necessary and set forth in the Agreement. KFHPWA may review a Member's medical records for the purpose of verifying delivery and coverage of services and items. Based on a prospective, concurrent or retrospective review, KFHPWA may deny coverage if, in its determination, such services are not Medically Necessary. Such determination shall be based on established clinical criteria. KFHPWA will not deny coverage retroactively for services with Preauthorization and which have already been provided to the Member except in the case of an intentional misrepresentation of a material fact by the patient, Member, or provider of services, or if coverage under this Agreement was obtained based on inaccurate, false, or misleading information provided on the enrollment application; or for nonpayment of premiums.

Utilization Management. All benefits are limited to Covered Services that are Medically Necessary and set forth in the AgreementBenefits Booklet. KFHPWA may review a Member's medical records for the purpose of verifying delivery and coverage of services and items. Based on a prospective, concurrent or retrospective review, KFHPWA may deny coverage if, in its determination, such services are not Medically Necessary. Such determination shall be based on established clinical criteria. KFHPWA will not deny coverage retroactively for services with Preauthorization and which have already been provided to the Member except in the case of an intentional misrepresentation of a material fact by the patient, Member, or provider of services, or if coverage under this Agreement was obtained based on inaccurate, false, or misleading information provided on the enrollment application; , or for nonpayment of premiums.

Utilization Management. ‌ DRAFT All benefits are limited to Covered Services that are Medically Necessary and set forth in the Agreement. KFHPWA may review a Member's medical records for the purpose of verifying delivery and coverage of services and items. Based on a prospective, concurrent or retrospective review, KFHPWA may deny coverage if, in its determination, such services are not Medically Necessary. Such determination shall be based on established clinical criteria. KFHPWA will not deny coverage retroactively for services with Preauthorization and which have already been provided to the Member except in the case of an intentional misrepresentation of a material fact by the patient, Member, or provider of services, or if coverage under this Agreement was obtained based on inaccurate, false, or misleading information provided on the enrollment application; or for nonpayment of premiums.