Search results with tag "Utilization management"
Provider Manual Section 5.0 Utilization Management
passporthealthplan.comPage 2 of 8 5.0 Utilization Management 5.1 Utilization Management Utilization Management (UM) is the evaluation of the medical necessity, quality, appropriateness
THE HOSPITAL CASE MANAGEMENT ORIENTATION MANUAL
hcmarketplace.comshe provides hospital case management consulting services to ensure clients’ compliance with state and federal law and to ensure accurate reimbursement. As a consultant, she addresses hospital case management staff needs, such as education and orientation, competency testing, utilization management, readmission prevention, daily care coordination
Re: WellMed Referrals, Utilization Management and Claims ...
www.mypreferredprovider.com11/01/2014 Re: WellMed Referrals, Utilization Management and Claims Payment for Preferred Care Partners Medicare Advan tage M embers in Central Florida –Eff c ive Jan. 1, 2015 Dear Provider:
Managed Care 101: Utilization Management
www.apg.orgSlide 1 Managed Care 101: Utilization Management Melanie Lite Matthews CEO, Physicians of Southwest Washington. CAPG Symposium. October 27, 2016
JOB DESCRIPTION Job Title: Utilization Management Nurse ...
www.innovativecare.com13. Support company and departmental QA/QI initiatives. Qualifications: Education and/or Experience Required at Entry: 1. Two years of prior experience with Utilization Management.
RESOURCE GUIDE TO CASE MANAGEMENT
cdn-aem.optum.comJan 01, 2016 · 1. Does the utilization review (UR) plan reflect a consistent process that is compliant with the UR standards as outlined in the Medicare Conditions of Participation (CoPs)? 2. Does case/utilization management follow a process of strict application of inpatient screening criteria for all Medicare beneficiaries as directed by the Hospital
Texas Resilience and Recovery
www.hhs.texas.govsituation and prevent utilization of more intensive services. The desired outcome is resolution of the crisis and avoidance of intensive and restrictive intervention or relapse. These services do not require prior authorization. However, Utilization Management (UM) staff must authorize the crisis service within 2 business days of presentation.
Effective Case Management Models: Which Should You Use?
wwwfiles.ahcmedia.comintegration of utilization management into the case manager role vs. separate um / drg specialist role 25. advantages of each model integrated model ... 4/4/2014 9:00:11 am ...
Cigna COVID-19 Medicare Advantage Billing & Authorization ...
medicareproviders.cigna.comUtilization Management Guidelines (Revised 6/22/2020) Authorization Requirements . Cigna requires authorization of certain services, medications, procedures, and/or equipment prior to performing or providing the service to prevent unnecessary utilization while safeguarding beneficiary access to the most appropriate medically necessary care.
PHARMACY AND THERAPEUTICS COMMITTEE
www.healthpartners.com8. The formulary will serve as a guideline for the vast majority of patients. a. Utilization management programs such as prior authorization, step-edits, MD -edits, quantity limits, and age limits will be applied to promote appropriate utilization. b. A “Formulary Exception” process will be readily available, easy to use, and timely. c.
Total Healthcare Management, Utilization Management and ...
www.bcbst.com• A voicemail box is available after business hours and on weekends/holidays so you can call us. • Contact the normal authorization line at 1- 800-924-7141
WellMed Texas Medicare Advantage Prior Authorization ...
www.wellmedhealthcare.comMay 01, 2021 · ©2020 WellMed Medical Management, Inc. ... • Utilization management • Discharge planning . The program includes: ... admissions, surgeries, procedures, referrals, evaluations, specialty services and/or treatments . Prior Authorization required for all recommendations from a network physician
Services that require authorization for Michigan providers
ereferrals.bcbsm.comDec 22, 2021 · For more complete information about care management and utilization management requirements, refer to the Medicare Plus Blue PPO Provider Manual. 1 Changes from the previous publication are identified by a Blue Dot and explained on the final page of this document.hanges from previous publication are marked with a Blue Dot and explained on the ...
Medicaid Health Plan Common Formulary - …
www.michigan.govState of Michigan Medicaid Health Plan Common Formulary Drug Class Drug Name Utilization Management ACE Inhibitor and Calcium Channel Blocker Combinations AMLODIPINE-BENAZEPRIL 10-20 MG QL
Extraspinal Manual Therapy - Logon
www.myoptumhealthphysicalhealth.comUtilization Management Policy *Optum is a brand used by OptumHealth Care Solutions, LLC and its affiliates . 1 . PLAIN LANGUAGE SUMMARY . Extraspinal Manual Therapy
Patient Healthcare Records: Documentation Requirements …
www.myoptumhealthphysicalhealth.comUtilization Management Policy *Optum is a brand used by OptumHealth Care Solutions, LLC and its affiliates . 1 . Patient Healthcare Records: Documentation Requirements for
I. HMO Responsibilities
www.bcbsil.comHMO Utilization Management BCBSIL Provider Manual—Rev 3/09 2 I. HMO Responsibilities A. HMO Program Structure Two health maintenance organizations exist within the managed care structure of Blue Cross and Blue Shield of
Texas Resilience and Recovery
www.hhs.texas.govAug 31, 2004 · The goals of the Utilization Management (UM) Guidelines are to increase understanding of TRR, guide the selection of levels of care and services, and serve as a reference tool for service providers. The UM Guidelines: Child and Adolescent Services manual should be distributed in its entirety to all
Utilization Management as a Cost-Containment Strategy
www.cms.govUtilization management as a cost-containment strategy by Howard L. Bailit and Cary Sennett . Utilization management (UM) is now an integral part of most public and private health plans. Hospital review, until recently the primary focus of UM, is associated with a reduction in bed days and rate of hospital cost increases.
Utilization Management Preauthorization Process Overview
www.bcbsil.comFollow instructions received for next steps. If your request is . approved: If an . adverse determination. is communicated: Submit your claim (Utilization management review is conducted.) Updated December 2020. UTILIZATION MANAGEMENT PROCESS OVERVIEW (COMMERCIAL) This information does not apply to review requests for any of our HMO or
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