Ariz. Admin. Code § R9-22-501 - General Provisions and Standards - Related Definitions
Current through Register Vol. 48, No. 14, April 8, 2022
In addition to definitions contained in A.R.S. § 36-2901, the words and phrases in this Chapter have the following meanings unless the context explicitly requires another meaning:
"Quality management" means a process used by professional health personnel through a formal program involving multiple organizational components and committees to:
Assess the degree to which services provided conform to desired medical standards and practices; and
Quality improvement or maintenance of care and services.
"Quality Improvement" means a process designed to achieve, through ongoing measurements and intervention, significant improvement that is sustained over time, in the areas of clinical care and non-clinical care and is expected to have a favorable effect on health outcomes and member satisfaction. Quality Improvement includes focusing organizational efforts on improving performance and utilizing data to develop intervention strategies to improve performance and outcomes.
"Utilization management/review" means a methodology used by professional health personnel to assess the medical indications, appropriateness, and efficiency of care provided. Utilization management applies to a contractor's process to evaluate and approve or deny the medical necessity, appropriateness, efficacy and efficiency of health care services, procedures, or settings. Utilization review includes processes for prior authorization, concurrent review, retrospective review, and case management.
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