Formal processes and systems utilized to help assure that members receive timely and appropriate health care and services.
An integrated working relationship between the managed care organization and the healthcare providers whereby medical protocols are established for the delivery of quality health care and the most positive clinical outcomes.
The protocols established and used by the Plan to ensure the Medical Necessity and Appropriateness of a selected procedure, treatment or other healthcare service based on the Plan's approved criteria.
A general term for programs that promote high-quality, cost-effective health care through such activities as utilization management, quality management and risk management.
Working with a doctor to talk about what medication, if any might be right for you, how you take the medication and how you feel when you take the medication. You are the most important part of managing your medication.
the use of medical information to help control the health risk posed by a contaminant in the workplace. The risk management decisions may be directed toward the entire workforce or they may be made for a single worker who is not able to safely work in an area due to a temporary or permanent medical condition.
The effective use of available health-care resources to prevent or manage work-related musculoskeletal disorders. Medical management is an element of the ergonomics program.