AUTHORIZATION AND DOCUMENTATION PROVISIONS. 1. SERVICE AUTHORIZATION A. CONTRACTOR will collaborate with COUNTY to complete authorization requests in line with COUNTY and DHCS policy.
AUTHORIZATION AND DOCUMENTATION PROVISIONS. 6.1. SUD NON-RESIDENTIAL AND NON-INPATIENT LEVELS OF CARE SERVICE AUTHORIZATION:
6.1.1. CONTRACTOR is not required to obtain service authorization for non-residential/non- inpatient levels of care. Prior authorization is prohibited for non-residential DMC-ODS services.
6.1.2. ASAM-based screening tools may be used when members call the DMC-ODS plan’s member access number or by providers in the DMC-ODS network to determine the appropriate location for treatment.
6.2. SUD RESIDENTIAL AND INPATIENT LEVELS OF CARE SERVICE AUTHORIZATION:
6.2.1. CONTRACTOR shall have in place, and follow, COUNTY written authorization policies and procedures for processing requests for initial and continuing authorization, or prior authorization, for residential treatment services, including inpatient services, but excluding withdrawal management services. DRAFT
6.2.2. COUNTY or designee will review the DSM and ASAM Criteria to ensure that the members meet the requirements for the service and will communicate authorization policies to network providers. Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested, shall be made by an individual who has appropriate expertise in addressing the member’s medical and behavioral health.
6.2.3. CONTRACTOR will collaborate with COUNTY to complete authorization requests in line with COUNTY and DHCS policy and procedures.
6.2.4. CONTRACTOR shall respond to COUNTY or designee in a timely manner when consultation is necessary for COUNTY to make appropriate authorization determinations.
6.2.5. COUNTY shall provide CONTRACTOR with written notice of authorization determinations within the timeframes set forth in BHIN 23-001, or any subsequent DHCS notices.
6.2.6. Authorization procedures and utilization management criteria shall:
6.2.6.1. Be based on DMC-ODS access criteria, including access criteria for members under age 21 pursuant to the EPSDT mandate.
6.2.6.2. Be consistent with current evidence-based clinical practice guidelines, principles, and processes.
6.2.6.3. Include mechanisms to ensure consistent application of review criteria for authorization decisions.
6.2.6.4. Provide for consultation with the requesting provider when appropriate.
6.2.6.5. Be developed with involvement from network providers.
6.2.6.6. Be evaluated at least annually and updated as necessary.
6.2.6.7. Be disclosed to the COUNTY’S members and network providers.
6.2.7. Prior authorizatio...
AUTHORIZATION AND DOCUMENTATION PROVISIONS. 1. SERVICE AUTHORIZATION
A. Contractor will collaborate with County to complete authorization requests in line with County and DHCS policy.
B. Contractor shall have in place, and follow, written policies and procedures for completing requests for initial and continuing authorizations of services, as required by County guidance.
C. Contractor shall respond to County in a timely manner when consultation is necessary for County to make appropriate authorization determinations.
D. County shall provide Contractor with written notice of authorization determinations within the timeframes set forth in BHINs 22-016 and 22-017, or any subsequent DHCS notices.
E. Contractor shall alert County when an expedited authorization decision (no later than 72 hours) is necessary due to a client’s specific needs and circumstances that could seriously jeopardize the client’s life or health, or ability to attain, maintain, or regain maximum function.
AUTHORIZATION AND DOCUMENTATION PROVISIONS
