Utilization Management Program means a program approved by BLUE CROSS and designed to review and manage the utilization of Covered Medical Services.
Utilization Management Program means a comprehensive approach and planned activities for evaluating the appropriateness, need, and efficiency of services, procedures, and facilities according to established criteria or guidelines. Utilization management typically includes new activities or decisions based upon the analysis of care, and describes proactive procedures, including discharge planning, concurrent planning, precertification, and clinical case Appeals. It also covers proactive processes, such as concurrent clinical reviews and Peer Reviews, as well as Appeals introduced by the Provider, payer, or Enrollee.
Utilization Management Program means either the utilization management program established and administered or subcontracted by Beech summarized in the Provider Manual or any utilization management program required by a Payor.
Examples of Utilization Management Program in a sentence
Our Drug Utilization Management Program features a set of closely aligned programs that are designed to promote Member safety, appropriate and cost-effective use of medications, and monitor healthcare quality.
However, this Section is not intended to, and will not, restrict any Utilization Management Program established by AvMed.
Our Drug Utilization Management Program features a set of closely aligned programs that are designed to promote Member safety, appropriate and cost effective use of medications, and monitor healthcare quality.
For covered drugs that are listed on the formulary, Our Drug Utilization Management Program, more fully described in the section below, may apply.
The UM Director is responsible for overseeing the day-to-day operational activities of the Utilization Management Program in accordance with state guidelines.
More Definitions of Utilization Management Program
Utilization Management Program means a system of reviewing the medical necessity, appropriateness, or quality of health care services and supplies provided under a managed care plan using specified guide- lines. Such a system may include, but is not limited to, preadmission certification, the application of practice guidelines, continued stay review, discharge planning, preauthorization of ambulatory procedures and retrospective review.
Utilization Management Program means the infrastructure required to carry out the 26 concurrent review services according to this Contract including, but not limited to, policies and 27 procedures, request staffing and information systems.
Utilization Management Program means a strategy designed to ensure that health care expenditures are restricted to those that are needed and appropriate by reviewing patient-inmate medical records through the application of defined criteria or expert opinion, or both. Utilization management assesses the efficiency of the health care process and the appropriateness of decisionmaking in relation to the site of care, its frequency, and its duration through prospective, concurrent, and retrospective utilization reviews.
Utilization Management Program means the process designed to review and determine, on a prospective, concurrent, and/or retrospective basis whether the medical procedure provided to a Member pursuant to the terms of the Benefit Healthcare Plan(s) and this Agreement is a Medically Necessary Service.
Utilization Management Program means (i) the utilization management program developed, established and administered by IPA or its agents for the determination of the medical necessity of Medical Services provided to Beneficiaries, (ii) a utilization management program developed by a Payor and administered by IPA, or (iii) a utilization management program developed, established and administered by a Payor.
Utilization Management Program means those procedures adopted by AvMed to assure that the supplies and services provided to Participants are Medically Necessary. These include, but are not limited to: (1) pre-authorization for all inpatient services, observation services, residential treatment, outpatient surgery, intensive outpatient programs, complex radiological imaging (CT, MRI, MRA, PET and Nuclear Cardiac Imaging), non-emergency ambulance, dialysis services, transplant services, use of Non-Participating Provider, select medications including injectables;(2) concurrent review of all patients hospitalized in acute care, psychiatric, rehabilitation, andSkilled Nursing Facilities, including on-site review when appropriate; (3) case management for all inpatients who need continued care in an alternative setting (such as homecare or a Skilled Nursing Facility) and for outpatients when deemed appropriate. The program may also advocate alternative cost-effective settings for the delivery of prescribed care and may identify other options for non-covered health care needs.
Utilization Management Program means a service(s) and/or utilization review service(s) performed through programs including, but not limited to, UM, MBH/SA, DM, DSM programs, offered by the Contractor which seek to assure that Covered Services provided to Eligible Members are in accordance with Plan provisions and appropriate under the standards and requirements established by this Contract.