Utilization management definition

Utilization management section means “you or your authorized representative.” Your representative will also receive all notices and benefit determinations.

Utilization management means a system for reviewing the

Utilization management means a set of formal techniques designed to monitor the

Examples of Utilization management in a sentence

• The Utilization Management Manager shall work with the Special Investigation Unit (SIU) Manager to assure that service billing and utilization issues are documented and reported to the SIU, and matters requiring SIU review or investigation shall be timely submitted within five (5) business days to enable recovery of overpayments or other appropriate action.

• The Utilization Management Manager shall, at a minimum, be responsible for directing the activities of the utilization management staff.

• With direct supervision by the Medical Director, the Utilization Management Manager shall direct staff performance regarding prior authorization, medical necessity determinations, concurrent review, retrospective review, appropriate utilization of health care services, continuity of care, care coordination and other clinical and medical management programs.

• The Contractor shall employ a Utilization Management Manager who is dedicated full-time to the Contractor’s Indiana Medicaid product lines.

• The Contractor shall maintain a Utilization Management plan and procedures consistent with the following: Staffing of all Utilization Management activities shall include, but not be limited to, a Medical Director, or Medical Director’s designee.

More Definitions of Utilization management

Utilization management means a set of formal techniques designed to monitor the use of, or evaluate the medical necessity, appropriateness, efficacy, or efficiency of, health care services, procedures, or settings.

Utilization management means a system for reviewing the appropriate and efficient allocation of health care services under a health benefits plan according to specified guidelines, in order to recommend or determine whether, or to what extent, a health care service given or proposed to be given to a covered person should or will be reimbursed, covered, paid for, or otherwise provided under the plan. The system may include preadmission certification, the application of practice guidelines, continued stay review, discharge planning, preauthorization of ambulatory care procedures, and retrospective review.

Utilization management means a system for administering some or all of an insurer’s decision point review plan, including but not limited to, receiving and responding to decision point review and precertification requests, making determination of medical necessity, scheduling and performing independent medical examinations (IMEs) bill review and handling of provider appeals.

Utilization management means a system for reviewing the appropriate and

Utilization management means the evaluation of medical necessity and appropriateness of the use of health care services, procedures, and facilities utilized by a Covered Person under the terms of the Plan.

Utilization management. The process of evaluating the necessity, appropriateness and efficiency of health care services against established guidelines and criteria.

Utilization management means a set of formal