دليل المزود

الامتثال لبرنامج تحسين الجودة وإدارة الاستخدام

Carelon has developed extensive Continuous Quality Improvement and Utilization Management Programs that ensure that service is of the highest possible quality. These measures include, but are not limited to, clinical criteria, controlled studies, surveys, evaluations, quality of care concern and complaint investigation and audits. Providers and practitioners who have signed a contract agree to permit oversight, while adhering to relevant state and federal confidentiality laws. Provider and practitioner cooperation with Carelon’s Quality Improvement activities is required in order to improve the quality of care and services and member experience. Cooperation includes collection and evaluation of data, timely response to quality of care, reportable event, and complaint investigations, and participation in the Carelon’s Quality Improvement programs. Refusal to cooperate with Carelon’s Quality Improvement or Utilization Management activities may adversely affect continued network participation or result in sanctions up to and including disenrollment.