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

• Provider shall comply with the requirements of, and shall participate in, applicable MA Program Utilization Management programs, as such programs may be clarified, amended or supplemented from time to time, and the decisions, rules and regulations established under such programs.

• Blue Shield will not retroactively deny Provider’s claims on the basis of Medical Necessity for services reviewed and Authorized pursuant to the Quality Improvement and Utilization Management Program, provided that Provider submitted full and accurate information to Blue Shield for review under its Quality Improvement and Utilization Management Program.

• OhioHealthy or its designee may be responsible for Utilization Management for a Payor if OhioHealthy and such Payor execute a Service Agreement setting forth the terms of such.

• In those situations, the applicable Utilization Management policies, procedures and requirements will be available directly from the Payor.

• Some of these Agents may include but are not limited to the Utilization Management Contractor(s) that will perform designated Prior Authorization, data analyses, and related functions; the Fiscal Agent that will process Contractor Member Encounter Data, provide Enrollment assistance to Members, and manage Provider credentialing; Auditors; the Pharmacy Benefits Administrator that will manage pharmacy prior authorization, claims management, and network; and the External Quality Review Organization.

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