Authorization of Services and Notices of Actions Sample Clauses

Authorization of Services and Notices of Actions. Clinical professionals who have appropriate clinical expertise in the treatment of a member’s condition or disease shall make all decisions to deny a service authorization request or to authorize a service in an amount, duration or scope that is less than requested. Only licensed physicians and nurses may deny a service authorization request or authorize a service in an amount, duration or scope that is less than requested. The Contractor shall not provide incentives to utilization management staff or to providers for denying, limiting or discontinuing medically necessary services. OMPP may audit Contractor denials, appeals and authorization requests. OMPP may waive certain administrative requirements, including prior authorization procedures, to the extent that such waivers are allowed by law and are consistent with policy objectives. The Contractor may be required to comply with such waivers and will be provided with prior notice by OMPP. If the Contractor delegates some or all of its prior authorization function to subcontractors, the Contractor shall conduct annual audits and ongoing monitoring to ensure the subcontractor’s performance complies with the Contract, the Contractor’s policies and procedures and state and federal law. As part of the utilization management function, the Contractor shall facilitate PMPs’ requests for authorization for primary and preventive care services and shall assist the PMP in providing appropriate referral for specialty services by locating resources for appropriate referral. In accordance with federal regulations, the process for authorization of services shall comply with the following requirements:  Second Opinions: In accordance with 42 CFR 438.206(b)(3), the Contractor must comply with all member requests for a second opinion from a qualified professional. If the provider network does not include a provider who is qualified to give a second opinion, the Contractor shall arrange for the member to obtain a second opinion from a provider outside the network, at no cost to the member.

Authorization of Services and Notices of Actions. Clinical professionals who have appropriate clinical expertise in the treatment of a member’s condition or disease must make all decisions to deny a service authorization request or to authorize a service in an amount, duration or scope that is less than requested. The MCO must not provide incentives to utilization management staff for denying, limiting or discontinuing medically necessary services. As part of the utilization management function, the MCO must facilitate its PMPs’ requests for authorization for primary and preventive care services and must assist the PMP in providing appropriate referral for specialty services. In accordance with Federal regulations, the process for authorization of services must comply with the following requirements: • Second Opinions: In accordance with 42 CFR 438.206(b)(3) the MCO must comply with all member requests for a second opinion from a qualified professional. If the provider network does not include a provider who is qualified to give a second opinion, the MCO must arrange for the member to obtain a second opinion from a provider outside the network, at no cost to the member.