Retrospective Utilization Review definition

Retrospective Utilization Review means a form of utilization review for health care services that have been provided to a member. Retrospective utilization review does not include review of services for which prospective or concurrent utilization reviews were previously conducted or should have been previously conducted.
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Examples of Retrospective Utilization Review in a sentence

  • Retrospective Utilization Review Retrospective DUR activities are implemented after medications have been dispensed to health plan members.

  • The balance ofthe payment shall be made upon completion of construction and testing of the subloop(s).

  • In the case of ongoing services, coverage will be continued without liability to you until you have been notified of an adverse determination.‌Discharge planning is incorporated as part of the concurrent review process and may also be provided upon the request of your Provider.• Retrospective Utilization Review.

  • For claims that require Utilization Review determinations, such notification will be provided in accordance with the provisions under “Prospective and Retrospective Utilization Review Determinations” below.

  • Retrospective Utilization Review 4.It is recommended that the IHA Companies, with respect to their Level of Care Change policy which is used to reduce prior hospital claim payments from in-patient stays to the lower observation rates, enact such policy as medical necessity denials of health care services pursuant to Section 4903.4 of the New York Public Health Law (IHA) and Section 4903(d) of the New York Insurance Law (IHBC).10 The Companies have complied with this recommendation.

  • E.1DSHS Retrospective Utilization Review (UR)....................................................

  • D.1.2. UM, as used in this RFP, includes practices such as Registration, Prior Authorization, Concurrent Review, Retroactive Medical Necessity Review and Retrospective Utilization Review.

  • Retrospective Utilization Review means Utilization Review conducted after services have been provided to an Insured Person.

  • Retrospective Utilization Review Determinations‌The following procedures apply to reviews of determinations made after services have been rendered: Step 1: Reconsideration If the Review Center has not approved a request for a medical service that has already been received, the Plan Member, treating provider, or facility may request a reconsideration review by a Review Center physician advisor.

  • UM as used in this RFP includes practices such as Registration, Prior Authorization, Concurrent Review, Retroactive Medical Necessity Review and Retrospective Utilization Review.

Related to Retrospective Utilization Review

  • Utilization review means the prospective (prior to), concurrent (during) or retrospective (after) review of any service to determine whether such service was properly authorized, constitutes a medically necessary service for purposes of benefit payment, and is a covered healthcare service under this plan. WE, US, and OUR means Blue Cross & Blue Shield of Rhode Island. WE, US, or OUR will have the same meaning whether italicized or not. YOU and YOUR means the subscriber or member enrolled for coverage under this agreement. YOU and YOUR will have the same meaning whether italicized or not.

  • Utilization review plan or "plan" means a written procedure for performing review.

  • Retrospective review means a review of medical necessity conducted after services have been provided to a patient, but does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding, or adjudication for payment.

  • Level V Pricing applies on any day if no other Pricing Level applies on such day.

  • Level III Pricing applies on any day on which (i) the Borrower’s long-term debt is rated A- or higher by S&P or A3 or higher by Moody’s and (ii) neither Level I Pricing nor Level II Pricing applies.

  • Level IV Pricing applies on any day on which (i) the Borrower’s long-term debt is rated BBB+ or higher by S&P or Baa1 or higher by Moody’s and (ii) none of Level I Pricing, Level II Pricing or Level III Pricing applies.

  • Utilization review organization means an entity that conducts utilization review, other than a health carrier performing a review for its own health plans.

  • Peer review means evaluation of professional services rendered by a professional practitioner.

  • Yearly (1/Year) sampling frequency means the sampling shall be done in the month of September, unless specifically identified otherwise in the effluent limitations and monitoring requirements table.

  • Enrollee point-of-service cost-sharing or "cost-sharing" means amounts paid to health carriers directly providing services, health care providers, or health care facilities by enrollees and may include copayments, coinsurance, or deductibles.

  • Level II Pricing applies on any day on which (i) the Borrower’s long-term debt is rated A or higher by S&P or A2 or higher by Moody’s and (ii) Level I Pricing does not apply.

  • Non-Participating Certified Clinical Nurse Specialist means a Certified Clinical Nurse Specialist who does not have a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • Level I Pricing applies on any day on which the Borrower’s long-term debt is rated A+ or higher by S&P or A1 or higher by Moody’s.

  • Independent educational evaluation means an evaluation conducted by a qualified examiner who is not employed by the public agency responsible for the education of the child in question.

  • Peer support specialist means an individual who has experienced a severe and persistent mental illness and who has successfully completed standardized training to provide peer support services through the medical assistance program or the Iowa Behavioral Health Care Plan.

  • Design Criteria Package means concise, performance-oriented drawings or specifications for a public construction project. The purpose of the Design Criteria Package is to furnish sufficient information to permit Design-Build Firms to prepare a bid or a response to the District’s Request for Proposals, or to permit the District to enter into a negotiated Design- Build Contract. The Design Criteria Package must specify performance- based criteria for the public construction project, including the legal description of the site, survey information concerning the site, interior space requirements, material quality standards, schematic layouts and conceptual design criteria of the project, cost or budget estimates, design and construction schedules, site development requirements, provisions for utilities, stormwater retention and disposal, and parking requirements applicable to the project. Design Criteria Packages shall require firms to submit information regarding the qualifications, availability, and past work of the firms, including the partners and members thereof.

  • Yearly (1/Year) sampling frequency means the sampling shall be done in the month of September, unless specifically identified otherwise in the effluent limitations and monitoring requirements table.

  • Clinical review criteria means the written screening procedures, decision abstracts, clinical protocols, and practice guidelines used by a health carrier to determine the necessity and appropriateness of health care services.

  • MCO means an organization having a certificate of authority or certificate of registration from the 11 Washington State Office of Insurance Commissioner that contracts with HCA under a comprehensive 12 risk contract to provide prepaid health care services to eligible HCA Enrollees under HCA managed 13 care programs.

  • Utilization means public usage of the subway, bus, railroad

  • Reliability Pricing Model Auction or “RPM Auction” shall mean the Base Residual Auction or any Incremental Auction, or, for the 2016/2017 and 2017/2018 Delivery Years, any Capacity Performance Transition Incremental Auction.

  • Participating Certified Clinical Nurse Specialist means a Certified Clinical Nurse Specialist who has a written agreement with the Claim Administrator or another Blue Cross and/or Blue Shield Plan to provide services to you at the time services are rendered.

  • MERS Procedure Manual The MERS Procedures Manual, as it may be amended, supplemented or otherwise modified from time to time.

  • Monitoring Indicator means a measure of HSP performance that may be monitored against provincial results or provincial targets, but for which no Performance Target is set;

  • Sustainability Factors means environmental, social and employee matters, respect for human rights, anti‐corruption and anti‐bribery matters.

  • Periodic Review means a review conducted by Ofwat for the purpose of determining one or more Price Controls in accordance with Part III of Condition B, but so that references in Part IV of Condition B to a Periodic Review shall exclude any review carried out under paragraph 11 of that Condition and shall include the determination by the Competition and Markets Authority of the relevant questions or, as the case may be, the disputed determination referred to it under paragraph 16 of Condition B;