Utilization review process definition

Utilization review process means utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify or deny, based in whole or in part on medical necessity to cure or relieve, treatment recommendations by physicians, as defined in Labor Code section 3209.3, prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Labor Code section 4600. The utilization review process begins when the completed DWC Form RFA, or a request for authorization accepted as complete under section 9792.9.1(c)(2), is first received by the claims administrator, or in the case of prior authorization, when the treating physician satisfies the conditions described in the utilization review plan for prior authorization.

Utilization review process means utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, delay, or deny, based in whole or in part on medical necessity to cure or relieve, treatment recommendations by physicians, as defined in Labor Code section 3209.3, prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Labor Code section 4600. Utilization review does not include determinations of the work-relatedness of injury or disease, or bill review for the purpose of determining whether the medical services were accurately billed.

Utilization review process means utilization management functions that prospectively, retrospectively or concurrently review and approve, modify, delay or deny, based in whole or in part on medical necessity to cure or relieve, treatment recommendations by physicians, prior to, retrospectively, or concurrent with the provisions of medical treatment services.

Examples of Utilization review process in a sentence

• EmblemHealth will provide an external appeal application with the final adverse determination issued through EmblemHealth’s Utilization review process or its written waiver of an internal appeal.

• The County will provide semi-automatic handguns, as per State Statutes, also ammunition and any other necessary weapons to all Deputies.

• Utilization review process - legislative declaration - cash fund.

• Standardized service definitions including units of service; Establishment of standards for documentation; Establishment of provider qualifications (credentials); Authorization and reauthorization of the identified services; Utilization review process: and Development of an appeal process.

• Utilization review process calls for assessing patients at every point of entry.

• Utilization review process encompasses intitial, concurrent and retrospective reviews.

• Utilization review process assesses theappropriateness of admission.

• Under the Equality Act 2010, it is unlawful to discriminate in the provision of goods and services on the basis of gender reassignment or sexual orientation.

• Utilization review process and criteria‌Utilization review overview‌Utilization review is the process of determining whether a given service is eligible for coverage or payment under the terms of a Member’s benefits plan and/or a network Provider’s contract.In order for a service to be covered or payable, it must be listed as included in the benefits plan, it must not be specifically excluded from coverage, and it must be Medically Necessary.

More Definitions of Utilization review process

Utilization review process means the utilization management functions thatprospectively, retrospectively, or concurrently review and approve, modify, delay or deny based in whole or in part on medical necessity to cure or relieve, treatment recommendations by physicians prior to, retrospectively, or concurrent with the provision of medical treatment. PROCEDURES FOR POLICY COMPLIANCEPolicies:1. Treatment Requests can be modified or denied only by a physician. At the Zenith, we utilize external Clinical Peer Review for denials and either external Peer Review or an internal Zenith Medical Officer for modifications. No Zenith employee may override (or attempt to override by additional opinions) a decision for coverage, modification or denial made by a Zenith Medical Officer or external Clinical Peer Review.If compensability has not yet been determined and the basis for denial is medical necessity, the denial must be rendered by external Clinical Peer Review. If the denial is based on compensability still being undetermined, then the denial must be approved by a Zenith Medical Officer. If the denial is procedural (e.g. treatment outside of the network, treatment request not made by a party authorized to treat under the law, or other reasons not based in causation or medical necessity) the underlying request for authorization does not meet the definition of a treatment request and is not subject to this policy, therefore the claim handler is authorized to respond to these requests in compliance with the law. 2. Determinations and recommendations made by a Zenith Medical Officer or external Clinical Peer Review must be followed and implemented in a timely manner subject to the Internal Review Process set out in (3) below.3. Internal Review Process: In the event an employee disagrees with or has legal process or other concerns regarding a utilization review determination made by a Zenith Medical Officer, or external Clinical Peer Review, the determination must be escalated for an interdepartmental branch staffing (with representation from claims, legal and medical management) within one business day.The employee must immediately schedule the interdepartmental file review staffing meeting to address the concerns or issues arising from the utilization review determination. The review staffing meeting must include the appropriate departmental AVP, any Zenith Medical Officer involved in the determination and if none, a Zenith Medical Officer and other appropriate Medical Management, Claims Mana...

Utilization review process means utilization management functions that prospectively, retrospectively, or concurrently review and Approve, Modify, or Deny, based in whole or in part on Medical Necessity to cure or relieve, treatment recommendations by physicians (as defined in LC § 3209.3), prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to LC § 4600.

Utilization review process means utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, delay, or deny, based in whole or in

Utilization review process means utilization management functions that prospectively, retrospectively, or concurrently review and approve, modify, or deny, based in whole or in part on medical necessity to cure or relieve, treatment recommendations by physicians, as defined in Labor Code section 3209.3, prior to, retrospectively, or concurrent with the provision of medical treatment services pursuant to Labor Code section 4600.