Appropriateness Review Sample Clauses

Appropriateness Review. Appropriateness review is necessary only under the following circumstances: (i) When Ohio Med PPO members use non-network hospitals or providers; (ii) When Ohio Med Traditional Plus members use non-network hospitals or any provider; or (iii) When Ohio Med Traditional members use any hospital or provider. Appropriateness review is not necessary for Ohio Med PPO members using network hospital/providers, and Ohio Med Traditional Plus members using network hospitals. For persons required to use it, an appropriateness review program shall be used to pre- authorize selected procedures (including magnetic resonance imaging [MRI] and positron emission tomography [PET] procedures) when performed on an inpatient basis or outpatient basis. The procedures requiring appropriateness review pre-authorization are listed in the Employee Benefit Handbook. The list may be altered by the Employer after consultation with the JHCC at least 45 days prior to the effective date of the change. Ohio Med members must be notified of the change prior to implementation. The Ohio Med plan administrator shall maintain a toll free customer service phone line with hours set in consultation with the JHCC to provide information about the appropriateness review procedure and assist employees and dependents in obtaining the necessary appropriateness review pre-authorization.