Utilization Management Programs definition

Utilization Management Programs means those comprehensive initiatives that are designed to validate medical appropriateness, including Medical Necessity, and to coordinate Covered Services and supplies, including: a. concurrent review of all patients hospitalized in acute care, psychiatric, rehabilitation, and Skilled Nursing Facilities, including on-site review when appropriate; b. case management and discharge planning for all inpatients and those requiring continued care in an alternative setting (such as home care or a Skilled Nursing Facility) and for outpatients when deemed appropriate; and c. prospective reviews for select Health Care Services to ensure that services are Medically Necessary Covered Benefits under this Contract.

Utilization Management Programs means those comprehensive initiatives that are designed to validate medical appropriateness, including Medical Necessity, and to coordinate Covered Services and supplies, including:

Utilization Management Programs means programs and activities, including, but not limited to, those identified in Appendix B of this Agreement and the Pricing Schedule, designed for the purpose of improving health and safety of Enrollees who purchase Covered Drugs, promoting cost savings and, where appropriate, encouraging the dispensing of Covered Drugs that are chemically different but deemed therapeutically similar to the Drug prescribed, and similar activities with like objectives.

Examples of Utilization Management Programs in a sentence

• We have established (and from time to time establish) various Member-focused health education and information programs as well as benefit Utilization Management Programs and utilization review programs.

• We have established (and from time to time establish) various Member- focused health education and information programs as well as benefit Utilization Management Programs and utilization review programs.

• With the objective of ensuring the fair and appropriate distribution of budgeted SCDHHS Dental Program dollars, DentaQuest’s Utilization Management Programs will help identify those dentists whose patterns show significant deviation from the normal practice patterns of the community of their peer dentists (typically less than 5% of all dentists).

• Utilization Management Programs include concurrent, retrospective and prospective review of certain services and procedures to assure that care is delivered in the most appropriate setting and is Medically Necessary.

• The UM Subcommittee reviews and approves the Utilization Management Programs annually.

• DentaQuest’s Utilization Management Programs recognize that there exists a normal individual dentist variance within these patterns among a community of dentists and accounts for such variance.

• Several Pharmaceutical Utilization Management Programs apply to this coverage with Capital.

• Kaiser Permanente Quality Improvement and Utilization Management Programs are designed to identify opportunities for improving health care provided to members.

• With this in mind, DentaQuest’s Utilization Management Programs are designed to ensure the fair and appropriate use of Federal and State program dollars as defined by the regionally based community practice patterns of local dentists and their peers.

• DentaQuest’s Utilization Management Programs evaluate claims submissions in such areas as: • Diagnostic and preventive treatment;• Patient treatment planning and sequencing;• Types of treatment;• Treatment outcomes; and• Treatment cost effectiveness.