West Virginia Code of State Rules
Agency 114 - Insurance Commission
Title 114 - LEGISLATIVE RULE INSURANCE COMMISSIONER
Series 114-51 - Utilization Management
Section 114-51-3 - Goals of Utilization Management Program
Universal Citation: 114 WV Code of State Rules 114-51-3
Current through Register Vol. XLI, No. 38, September 20, 2024
3.1. The goals of a health maintenance organization's utilization management program shall be to:
a. Assure the provision of appropriate medical
services delivered to members, while simultaneously addressing the effectiveness and
quality of care;
b. Monitor, evaluate
and improve the delivery of health care and resource utilization;
c. Provide a systematic process that promotes the
delivery of medically appropriate care in a timely, effective and efficient manner,
while maintaining the quality of health care;
d. Continually upgrade monitoring procedures to
re-evaluate performance goals;
e.
Monitor utilization practices of provider physicians, hospitals and ancillary
providers; and
f. Direct members and
providers toward the goal of quality, cost effective health care.
3.2. The health maintenance organization's utilization management program shall include a mechanism for identifying potential quality of care issues and linking them to the HMO's quality assurance program.
Disclaimer: These regulations may not be the most recent version. West Virginia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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