Section 38Sec./Art. 38

Safeguards Against Over and Under Utilization. - It is incumbent upon the Corporation to set up a monitoring mechanism to be operationalized through a contract with health care providers to ensure that there are safeguards against:

a) over-utilization of services;

b) unnecessary diagnostic and therapeutic procedures and intervention;

c) irrational medication and prescriptions;

1) under-utilization of services; and

2) inappropriate referral practices.

The Corporation may deny or reduce the payment for claims when such claims are attended by false or incorrect information and when the claimant fails without justifiable cause to comply with the pertinent rules and regulations of this Act.

Article IX. GRIEVANCE AND APPEAL