Clinical Review. The Department may choose to perform a clinical review of the Pay-for-Performance program. The PH-MCO must reasonably cooperate with Department staff during the clinical review process.
Clinical Review. Xxxxxxxx will confirm with the prescribing physician and other health care providers whether certain Prescription Drugs are being prescribed for medical conditions consistent with FDA-approved indications and labeling. In providing any or all such services, Xxxxxxxx may rely upon information provided by the Member or such person’s representative, the prescribing physician or health care provider, the dispensing pharmacist and other sources deemed reliable by Xxxxxxxx. Benecard shall not determine medical necessity or appropriateness of treatment. In determining if a prescription Claim is payable, Benecard may rely upon protocols established and maintained by commonly recognized medical sources or compendia or an advisory Pharmacy and Therapeutics Committee based upon factors such as safety, availability, potential for misuse and cost in its review of Claims submitted for payment of such Prescription Drugs. Group acknowledges that Xxxxxxxx may suspend processing of Claims for Prescription Drugs subject to Clinical Review procedures in the event the prescribing physician or health care provider fails to provide any information necessary for the processing of such Claims in compliance with such protocols. The decision to prescribe and dispense any drug shall remain within the professional judgment of the physician or health care provider and the pharmacist, respectively.
Clinical Review. A clinical review is conducted by representatives from a hospital and DMH who are delegated by the DMH Commissioner to serve this function and review any materials submitted relevant to the decision. Delegated staff may issue a decision or request additional information from persons with knowledge of the issues prior to deciding. The DMH Medical Director will render a determination regarding authorizing or denying the payment. If the DMH Medical Director believes additional consultation is needed to render a determination he/she may informally consult with another psychiatrist, who has no vested interest in the determination, regarding medical/clinical necessity and the clinical review process or consult with the Department of Vermont Health Access Medical Director prior to making a determination. In any instance of a denial at this level, the provider may request an appeal to the DMH Commissioner for reconsideration. *In any instance when payment will be denied, the patient and his or her authorized representative will be notified of his/her right to appeal and the process by which he or she may do so. The hospital may only enter an appeal on behalf of the patient. The patient or his or her authorized representative must authorize this appeal. Attachment H Department of Vermont Health Access Subcontractor Compliance Form Date: Original Contractor/Grantee Name: Contract/Grant #: Subcontractor Name: Scope of Subcontracted Services: Is any portion of the work being outsourced outside of the United States? 🞎 YES 🞎 NO (If yes, do not proceed) All vendors under contract, grant, or agreement with the State of Vermont, are responsible for the performance and compliance of their subcontractors with the Standard State Terms and Conditions in Attachment C. This document certifies that the Vendor is aware of and in agreement with the State expectation and has confirmed the subcontractor is in full compliance (or has a compliance plan on file) in relation to the following: 🞎 Subcontractor does not owe, is in good standing, or is in compliance with a plan for payment of any taxes due to the State of Vermont 🞎 Subcontractor (if an individual) does not owe, is in good standing, or is in compliance with a plan for payment of Child Support due to the State of Vermont. 🞎 Subcontractor is not on the State’s disbarment list. In accordance with State Standard Contract Provisions (Attachment C), the State may set off any sums which the subcontractor owes the State against ...
Clinical Review. Highmark shall submit the claim(s) tied to the disputed care (“disputed claim”) to teams of two clinicians, one designated by UPMC and the other by Xxxxxxxx, who have the authority to determine for each party whether the claim qualifies as In-Network under the Continuity of Care provision. The Clinical Review will occur within 15 days of submission of the disputed claim to the clinicians for review. UPMC will provide the reviewing clinicians with appropriate supporting clinical information or documentation for the claim(s).
