Authorization of Services a. The Contractor and its subcontractors shall have in place, and follow, written authorization policies and procedures.
Authorization of Services. Contractor shall have in place and follow written policies and procedures when processing requests for initial and continuing authorizations of Covered Services. Such policies and procedures shall provide for consistent application of review criteria for authorization decisions by a health care professional or professionals with expertise in treating the Enrollee’s condition or disease and provide that Contractor shall consult with the Provider requesting such authorization when appropriate. If Contractor declines to authorize Covered Services that are requested by a Provider or authorizes one or more services in an amount, scope, or duration that are less than that requested, Contractor shall notify the Provider orally or in writing and shall furnish the Enrollee with written notice of such decision. Such notice shall meet the requirements set forth in 42 C.F.R. 438.404.
Authorization of Services. The Contractor will not provide authorization for inpatient hospital services. Providers will continue to seek authorization from the agency’s QIO Contractor. The Contractor must define service authorization in a manner that at least includes an Enrollee’s request for the provision of a service. The Contractor must have in place written policies and procedures for the processing of requests for initial and continuing authorizations of services. The Contractor must have a mechanism to ensure consistent application of review criteria for authorization decisions that includes consultation with the requesting provider when appropriate. Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested must be made by a health care professional who has appropriate clinical expertise in treating the Enrollee’s condition or disease. The Contractor must notify the requesting provider and the Enrollee in writing of any decision by the Contractor to deny an authorization request or to authorize a service in an amount, duration, or scope that is less than requested. The notice must meet the requirements specified in 42 CFR § 438.404. For standard authorization decisions, the Contractor must provide notice within fourteen (14) calendar days following receipt of the request for services with a possible extension of up to fourteen (14) additional calendar days if the Enrollee or the provider requests an extension or the Contractor justifies to the Division a need for additional information and how the extension is in the Enrollee’s best interest. Expedited authorization decisions are those in which a provider indicates or the Contractor determines that following the standard authorization decision timeframe could seriously jeopardize the Enrollee’s life or health or ability to attain, maintain, or regain maximum function. The Contractor must provide decision notice no later than three (3) working days after receipt of the request for service for an expedited authorization request with a possible extension of up to fourteen (14) additional calendar days if the Enrollee or the provider requests an extension or the Contractor justifies to the Division a need for additional information and how the extension is in the Enrollee’s best interest. Compensation to individuals or utilization management entities must not be structured so as to provide incentives for the individual or entity to deny, limit, or ...
Authorization of Services. In accordance with 42 C.F.R. § 438.210, the Contractor shall authorize services as follows:
Authorization of Services. 1. - for services. Requirements will be discussed by both Parties and Contractor shall prepare a written Scope Statement to County that will include the specific work to be performed, including the costs and time required to complete the project/task.
Authorization of Services a. The LME/PIHP shall determine medical necessity for those services requiring prior authorization as set forth in Controlling Authority, including DMA Clinical Coverage Policies.
Authorization of Services. By either (a) returning a signed Quote; (b) submitting a signed purchase order referencing a Quote;
Authorization of Services. For the processing of requests for initial and continuing authorization of services, the CONTRACTOR shall:
Authorization of Services. 11.3.1 The Contractor shall provide education and ongoing guidance and training to Consumers and providers about its UM protocols and Level of Care Guidelines, including admission, continued stay, and discharge criteria.
Authorization of Services. F. Pursuant to 42 C.F.R. § 438.210(b), the Contractor shall implement mechanisms to assure authorization decision standards are met. The Contractor shall:
