W. Va. Code R. § 114-51-3

Current through Register Vol. XLI, No. 50, December 13, 2024

Section 114-51-3 - Goals of Utilization Management Program

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.

W. Va. Code R. § 114-51-3