COMPLIANCE WITH QUALITY IMPROVEMENT AND UTILIZATION MANAGEMENT PROGRAM
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, and audits. Providers who have signed a contract agree to permit oversight, while adhering to relevant state and federal confidentiality laws. 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. Provider participation is an integral part of Carelon’s quality management and utilization management programs and is a condition of network participation.