Utilization Review. NOTE: The Utilization Review process does not apply to Services that are not covered by Blue Shield because of a coverage determination made by Medicare. State law requires that health plans disclose to Subscribers and health plan providers the process used to authorize or deny health care services un- der the plan. Blue Shield has completed documen- tation of this process ("Utilization Review"), as required under Section 1363.5 of the California Health and Safety Code. To request a copy of the document describing this Utilization Review pro- cess, call the Customer Service Department at the telephone number indicated on your Identification Card.
Utilization Review. We review health services to determine whether the services are or were Medically Necessary or experimental or investigational ("Medically Necessary"). This process is called Utilization Review. Utilization Review includes all review activities, whether they take place prior to the service being performed (Preauthorization); when the service is being performed (concurrent); or after the service is performed (retrospective). If You have any questions about the Utilization Review process, please call the number on Your ID card. The toll-free telephone number is available at least 40 hours a week with an after-hours answering machine. All determinations that services are not Medically Necessary will be made by: 1) licensed Physicians; or 2) licensed, certified, registered or credentialed health care professionals who are in the same profession and same or similar specialty as the Provider who typically manages Your medical condition or disease or provides the health care service under review. We do not compensate or provide financial incentives to Our employees or reviewers for determining that services are not Medically Necessary. We have developed guidelines and protocols to assist Us in this process. Specific guidelines and protocols are available for Your review upon request. For more information, call the number on Your ID card or visit Our website at xxx.xxxxxxx.xxx.
Utilization Review. We review health services to determine whether the services are or were Medically Necessary or experimental or investigational ("Medically Necessary"). This process is called Utilization Review. Utilization Review includes all review activities, whether they take place prior to the service being performed (Preauthorization); when the service is being performed (concurrent); or after the service is performed (retrospective). If You have any questions about the Utilization Review process, please call the number on Your ID card. The toll-free telephone number is available at least 40 hours a week with an after-hours answering machine. All determinations that services are not Medically Necessary will be made by: 1) licensed Physicians; or 2) licensed, certified, registered or credentialed health care professionals who are in the same profession and same or similar specialty as the Provider who typically manages Your medical condition or disease or provides the health care service under review. We do not compensate or provide financial incentives to Our employees or reviewers for determining that services are not Medically Necessary. We have developed guidelines and protocols to assist Us in this process. Specific guidelines and protocols are available for Your review upon request. For more information, call the number on Your ID card or visit Our website at xxx.xxxxxx.xxx. You may ask that We send You electronic notification of a Utilization Review determination instead of notice in writing or by telephone. You must tell Us in advance if You want to receive electronic notifications. To opt into electronic notifications, call the number on Your ID card or visit Our website. You can opt out of electronic notifications at any time.
Utilization Review. If the M+C Organization uses written protocols for utilization review, those policies and procedures must reflect current standards of medical practice in processing requests for initial or continued authorization of services.[422.152(b)(3)]. The M+C Organization must also have in effect mechanisms to detect both underutilization and overutilization of services.[422.152(b)(4)] .
Utilization Review. The use of utilization and review activities ensures program fiscal integrity, addresses the state mandate requiring program funds be spent only as allowed under state laws and regulations, and ensures that services are based on medical necessity and efficacy of services provided. Records are chosen for review through a random sample or if billing issues are noted by CRS field staff. Review of individual records with services and billing occur from the point of entry into the CRS program until after the individual ends treatment and may include prospective, concurrent, and retrospective review activities. Additionally, Contractors are required to participate in cost reporting and cost surveys performed by the HHSC Rate Analysis Department.
Utilization Review. 7.1 The Home Health Care Agency shall adhere to and cooperate with XXXX's prior authorization procedures. These procedures do not guarantee a member’s eligibility or that benefits are payable, but assure the Home Health Care Agency that the medical services to be provided are covered under the Plan. Failure to obtain prior authorization shall result in the Home Health Care Agency’s reimbursement being penalized by 10% if medical necessity is confirmed retrospectively and, if not confirmed, there shall be no reimbursement.
7.2 EGID shall maintain review procedures and screening criteria that take into account professionally acceptable standards for quality home health care in the community. EGID or its designee shall consider all relevant information concerning the member before medical necessity is approved or denied.
7.3 The prior authorization requirements are intended to maximize insurance benefits assuring that services are provided to the member at the appropriate level of care. In no event is it intended that the prior authorization procedure interfere with the Home Health Care Agency’s decision regarding the patient’s care.
7.4 The Home Health Care Agency shall request prior authorization from EGID before providing home health care services. The Home Health Care Agency shall be prepared to give the following information:
a) patient’s name
b) member’s name
c) member’s social security number
d) patient’s age and sex
e) diagnosis and brief description of case
f) scheduled date services are to begin
g) patient status (i.e., employee, dependent)
h) treatment plan - to include physician’s letter of medical necessity, signed physician’s orders and estimated duration of service. The written plan must be submitted to the EGID.
7.5 EGID shall not retrospectively deny any previously approved care. The Home Health Care Agency and/or its designee shall update EGID, or its designee, as the member's condition or diagnosis changes. Updated information may result in a change of the originally approved length of stay.
7.6 Upon the member’s request, EGID shall reconsider any non-approved services. The Home Health Care Agency may submit a formal written appeal to EGID.
Utilization Review. (a) An MA Organization for an MA coordinated care plan must use written protocols for utilization review and policies and procedures must reflect current standards of medical practice in processing requests for initial or continued authorization of services and have in effect mechanisms to detect both underutilization and over utilization of services. [422.152(b)]
(b) For MA regional preferred provider organizations (RPPOs) and MA local preferred provider organizations (PPOs) that are offered by an organization that is not licensed or organized under State law as an HMOs, if the MA Organization uses written protocols for utilization review, those policies and procedures must reflect current standards of medical practice in processing requests for initial or continued authorization of services and include mechanisms to evaluate utilization of services and to inform enrollees and providers of services of the results of the evaluation. [422.152(e)]
Utilization Review. 6.6.1 Company shall not be required to pay any claim until it determines that Services provided to a Covered Person are Covered Services.
6.6.2 Company has the right to conduct utilization review on a prospective concurrent and/or retrospective basis, subject to compliance with PPACA applicable Claims Procedure Requirements.
Utilization Review. 13 8.1 CONTRACTOR and ADMINISTRATOR shall meet upon ADMINISTRATOR’s 14 request at CONTRACTOR’s facility identified in Paragraph 6 of this Exhibit A, 15 to review and evaluate a random selection of PARTICIPANT case records. The 16 review shall include, but is not limited to, an evaluation of the necessity 17 and appropriateness of services provided and length of services. PARTICIPANT 18 cases to be reviewed shall be randomly selected by ADMINISTRATOR.
19 8.2 In the event CONTRACTOR and ADMINISTRATOR are unable to resolve 20 differences of opinion regarding the necessity and appropriateness of services 21 and length of services, the dispute shall be submitted to COUNTY’s Director of 22 Children and Family Services for final resolution.
Utilization Review. Utilization review management services are provided by HEBP as the Claims Administrator. Concurrent reviews, discharge planning and retrospective reviews are designed to reduce the occurrence of unnecessary or inappropriate hospitalizations of patients.
