Common use of Utilization Review Clause in Contracts

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. 7.1 The Home Health Care Agency Infusion Therapy Provider shall adhere to and cooperate with XXXX's ’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 Infusion Therapy Provider that the medical professional services to be provided are covered under the Plan. Failure to obtain prior authorization shall result in the Home Health Care AgencyInfusion Therapy Provider’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 infusion therapy 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 AgencyInfusion Therapy Provider’s decision regarding the patient’s care. 7.3 EGID shall maintain review procedures and screening criteria that take into account professionally acceptable standards for quality medical care in the community. EGID or its designee shall consider all relevant information concerning the member before medical necessity is approved or denied. 7.4 EGID shall not retrospectively deny any previously approved care. The Home Health Care Agency Infusion Therapy Provider and/or its designee shall update EGID, or its designee, as the member’s condition or diagnosis changes. 7.5 Upon the member’s request, EGID shall reconsider any non-approved services. The Infusion Therapy Provider may submit a formal written appeal to EGID. 7.6 The Infusion Therapy Provider shall request prior authorization from EGID before providing home health care infusion therapy services. The Home Health Care Agency Infusion Therapy Provider 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. 7.1 The Home Health Care Agency Nurse Practitioner shall adhere to and cooperate with XXXX's precertification, concurrent review and prior authorization procedures. These procedures do not guarantee a member’s eligibility or that benefits are payable, but assure the Home Health Care Agency Nurse Practitioner that the medical services to be provided are covered under the Plan. 7.2 The Nurse Practitioner, or his/her representative, shall notify EGID, or its designee, of any admission. The Nurse Practitioner shall request precertification at least three days prior to the scheduled admission. A request for certification shall be made within one working day after an emergency admission or observation stay with duration greater than 24 hours. Such notification shall be at no charge to EGID or the member. Failure to obtain comply with the precertification, concurrent review or prior authorization requirements shall result in the Home Health Care AgencyNurse Practitioner’s reimbursement being penalized by 10% if medical necessity is confirmed retrospectively and, if not confirmed, there shall be no reimbursement. 7.2 7.3 The Nurse Practitioner or his/her representative shall notify EGID or its designee of any outpatient surgical procedure which is to be accomplished outside the Nurse Practitioner’s office. 7.4 The precertification, prior authorization and concurrent review requirements are intended to maximize insurance benefits assuring that hospital and medical services are provided to the member at the appropriate level of care. In no event is it intended that the procedures interfere with the Nurse Practitioners decision to order admission or discharge of the patient to or from the hospital. 7.5 EGID shall maintain review procedures and screening criteria that take into account professionally acceptable standards for quality home health medical 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 7.6 EGID, or its designee, shall respond to maximize insurance benefits assuring that services are provided requests for precertification by immediately assigning a code number 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 careeach request. 7.4 The Home Health Care Agency shall 7.7 At the time of the precertification request prior authorization from EGID before providing home health care services. The Home Health Care Agency shall the Nurse Practitioner should be prepared to give the following information: a) patient’s namemember's name and social security number, b) member’s nameage and sex, c) member’s social security numberdiagnosis, d) patient’s age and sexreason for admission, e) diagnosis and brief description scheduled date of caseadmission, f) scheduled date services are to beginplanned procedure or surgery, g) patient status (i.e., employee, dependent)scheduled date of surgery, h) treatment plan - to include physician’s letter name of medical necessityhospital, signed physician’s orders and estimated duration i) name 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 EGIDprovider, 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.and

Utilization Review. 7.1 The Home Health Care Agency Physician Assistant shall adhere to and cooperate with XXXX's precertification, concurrent review and prior authorization procedures. These procedures do not guarantee a member’s eligibility or that benefits are payable, but assure the Home Health Care Agency Physician Assistant that the medical services to be provided are covered under the Plan. 7.2 The Physician Assistant, or his/her representative, shall notify the, or its designee, of any admission. The Physician Assistant shall request precertification at least 3 days prior to the scheduled admission. A request for certification shall be made within one working day after an emergency admission or observation stay with duration greater than 24 hours. Such notification shall be at no charge to EGID or the member. Failure to obtain comply with the precertification, concurrent review or prior authorization requirements shall result in the Home Health Care AgencyPhysician Assistant’s reimbursement being penalized by 10by10% if medical necessity is confirmed retrospectively and, if not confirmed, there shall be no reimbursement. 7.2 7.3 The Physician Assistant or his/her representative shall notify EGID or its designee of any outpatient surgical procedure which is to be accomplished outside the Physician Assistant’s office. 7.4 EGID precertification, prior authorization and concurrent review requirements are intended to maximize insurance benefits assuring that hospital and medical services are provided to the member at the appropriate level of care. In no event is it intended that the procedures interfere with the Physician Assistant’s decision to order admission or discharge of the patient to or from the hospital. 7.5 EGID shall maintain review procedures and screening criteria that take into account professionally acceptable standards for quality home health medical 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 7.6 EGID, or its designee, shall respond to maximize insurance benefits assuring that services are provided requests for precertification by immediately assigning a code number 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 careeach request. 7.4 The Home Health Care Agency shall 7.7 At the time of the precertification request prior authorization from EGID before providing home health care services. The Home Health Care Agency shall the Physician Assistant should be prepared to give the following information: a) patient’s namemember's name and social security number, b) member’s nameage and sex, c) member’s social security numberdiagnosis, d) patient’s age and sexreason for admission, e) diagnosis and brief description scheduled date of caseadmission, f) scheduled date services are to beginplanned procedure or surgery, g) patient status (i.e.scheduled date of surgery, employee, dependent) h) treatment plan - to include physician’s letter name of medical necessityhospital, signed physician’s orders and estimated duration i) name 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 EGIDPhysician Assistant, 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.and

Utilization Review. 7.1 The Home Health Care Agency Pathology Group shall adhere to and cooperate with XXXXEGID's pre- certification, concurrent review and prior authorization procedures. These procedures do not guarantee a member’s eligibility or that benefits are payable, but assure the Home Health Care Agency physician that the medical services to be provided are covered under the Plan. 7.2 The Pathology Group, or its representative, shall notify EGID, or its designee, of any admission. The Pathology Group shall request precertification at least three days prior to the scheduled admission. A request for certification shall be made within one working day after an emergency admission or observation stay with duration greater than 24 hours. Such notification shall be at no charge to EGID or the member. Failure to obtain comply with the precertification, concurrent review or prior authorization requirements shall result in the Home Health Care AgencyPathology Group’s reimbursement being penalized by 10% if medical necessity is confirmed retrospectively and, if not confirmed, confirmed there shall be no reimbursement. 7.2 7.3 The Pathology Group or its representative shall notify EGID or its designee of any outpatient surgical procedure, which is to be accomplished outside the Pathology Group. 7.4 The precertification, prior authorization and concurrent review requirements are intended to maximize insurance benefits assuring that hospital and medical services are provided to the member at the appropriate level of care. In no event is it intended that the procedures interfere with the physician's decision to order admission or discharge of the patient to or from the hospital. 7.5 EGID shall maintain review procedures and screening criteria that take into account professionally acceptable standards for quality home health medical 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 7.6 EGID, or its designee, shall respond to maximize insurance benefits assuring that services are provided requests for precertification by immediately assigning a code number 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 careeach request. 7.4 The Home Health Care Agency shall 7.7 At the time of the precertification request prior authorization from EGID before providing home health care services. The Home Health Care Agency shall the Pathology Group should be prepared to give the following information: a) patient’s namemember's name and social security number, b) member’s nameage and sex, c) member’s social security numberdiagnosis, d) patient’s age and sexreason for admission, e) diagnosis and brief description scheduled date of caseadmission, f) scheduled date services are to beginplanned procedure or surgery, g) patient status (i.e.scheduled date of surgery, employee, dependent) h) treatment plan - to include name of hospital, i) name of 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.and