Authorization of Services a. The Contractor and its subcontractors shall have in place, and follow, written authorization policies and procedures.
b. The Contractor shall have in effect mechanisms to ensure consistent application of review criteria for authorization decisions.
c. The Contractor shall consult with the requesting provider for medical services when appropriate.
d. 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 beneficiary’s medical and behavioral health.
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. 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 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.
b. For those services requiring prior authorization, the LME/PIHP shall issue a decision to approve or deny a service within fourteen (14) calendar days after receipt of the request, provided that the deadline may be extended for up to fourteen (14) additional calendar days if:
1. The Enrollee requests the extension; or
2. The Contractor requests the extension; or
3. The LME/PIHP justifies to the Department upon request:
a) A need for additional information; and
b) How the extension is in the Enrollee’s interest.
c. In those cases for services requiring prior authorization in which Contractor indicates, or LME/PIHP determines, that adherence to the standard timeframe could seriously jeopardize an Enrollee’s life or health or ability to attain, maintain, or regain maximum function, including but not limited to psychiatric inpatient hospitalization services, LME/PIHP shall issue a decision to approve or deny a service within three calendar days after it receives the request for services, provided that the deadline may be extended for up to fourteen (14) additional calendar days if:
1. The Enrollee requests the extension; or
2. The LME/PIHP justifies to the Department upon request:
a) A need for additional information; and
b) How the extension is in the Enrollee’s interest.
d. For those services requiring prior authorization, the LME/PIHP shall permit retroactive authorization of such services in instances where the Enrollee has been retroactively enrolled in the Medicaid program or in the LME/PIHP program, or where the Enrollee has primary insurance which has not yet paid or denied its claim. Retroactive authorizations include requests for deceased Enrollees. The request for authorization must be submitted within ninety (90) days of primary denial or notice of enrollment.
e. Upon the denial of a requested authorization, the LME/PIHP shall inform Enrollee’s attending physician or ordering provider of the availability of a peer to peer conversation, to be conducted within one business day.
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.
2. County Project Manager or designee will review proposal, proceed with negotiations of costs and when satisfied, request Contractor to provide a final written proposal to County, which shall include the Scope Statement, Cost, Schedule, and Deliverables.
3. Upon written approval from County to proceed with services, Contractor shall perform services in accordance with the written proposal. Any changes to the original proposal shall be approved and authorized in writing in advanced by the County prior to performing the additional services.
Authorization of Services. By either (a) returning a signed Quote; (b) submitting a signed purchase order referencing a Quote;
Authorization of Services. Pursuant to 42 C.F.R. § 438.210(b), the Contractor shall implement mechanisms to assure authorization decision standards are met. The Contractor shall:
Authorization of Services a. The Contractor and its subcontractors shall have in place, and follow, written authorization policies and procedures.
b. The Contractor shall have in effect mechanisms to ensure consistent application of review criteria for authorization decisions.
c. The Contractor shall consult with the requesting provider for medical services when appropriate.
d. 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 beneficiary’s medical and behavioral health.
e. Notice of Adverse Benefit Determination (NOABD).
i. The Contractor shall notify the requesting provider, and give the beneficiary written notice of any decision by the Contractor to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The beneficiary’s notice shall meet the requirements of 42 CFR §438.404.
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.
11.3.2 The Contractor shall have in effect mechanisms to ensure consistent application of UMP review criteria for authorization decisions.
11.3.3 The Contractor shall consult with the requesting provider when appropriate.
Authorization of Services. In accordance with 42 C.F.R. § 438.210, the Contractor shall authorize services as follows:
2.11.5.1. For the processing of requests for initial and continuing authorizations of Covered Services, the Contractor shall:
2.11.5.1.1. Have in place and follow written policies and procedures;
2.11.5.1.2. Have in effect mechanisms to ensure the consistent application of review criteria for authorization decisions;
2.11.5.1.3. Have in place procedures to allow Enrollees to initiate requests for provision of services; and
2.11.5.1.4. Consult with the requesting Network Provider when appropriate.
2.11.5.2. The Contractor shall ensure that an authorized Care Coordinator is available twenty-four (24) hours a day for timely authorization of Covered Services that are Medically Necessary and to coordinate transfer of stabilized Enrollees in the emergency department, if necessary. The Contractor’s guidelines for medical necessity must, at a minimum, be consistent with Medicare standards for acute services and prescription drugs and Medi-Cal standards for LTSS.
2.11.5.3. 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 medical condition, performing the procedure, or providing the treatment. Behavioral Health services denials must be rendered by board-certified or board-eligible psychiatrists or by a licensed clinician, acting within their scope of practice, with the same or similar specialty as the Behavioral Health services being denied, except in cases of denials of service for psychological testing, which shall be rendered by a qualified psychologist.
2.11.5.4. The Contractor shall assure that all Behavioral Health authorization and utilization management activities are in compliance with 42 U.S.C. § 1396u-2(b)(8). Contractor must comply with the requirements for demonstrating parity for quantitative treatment limitations between Behavioral Health and medical/surgical inpatient, outpatient and pharmacy benefits.
2.11.5.5. The Contractor must notify the requesting Network Provider, either orally or in writing, and give the Enrollee written notice of any decision by the Contractor to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice must meet the requirements of 42 C.F.R. § 438.404 and Titl...
