Common use of Authorization of Services Clause in Contracts

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 Title 22 CCR § 53261, and must: 2.11.5.5.1. Be produced in a manner, format, and language that can be easily understood; 2.11.5.5.2. Be made available in Threshold Languages, upon request; 2.11.5.5.3. Include information, in Threshold Languages about how to request translation services and alternative formats. Alternative formats shall include materials which can be understood by persons with limited English proficiency: and 2.11.5.5.4. In any written communication to a physician or other health care provider of a denial, delay or modification of a request, include the name and telephone number of the health care professional responsible for the denial, delay or modification. 2.11.5.6. The Contractor must make authorization decisions in the following timeframes: 2.11.5.6.1. For standard authorization decisions, provide notice as expeditiously as the Enrollee’s health condition requires, within five (5) working days from receipt of the information reasonably necessary to render a decision, and in all circumstances no later than fourteen (14) calendar days after receipt of the request for service, with a possible extension not to exceed fourteen (14) additional calendar days. Such extension shall only be allowed if: 2.11.5.6.1.1. The Enrollee or the Provider requests an extension, or 2.11.5.6.1.2. The Contractor can justify (to the 2.11.5.6.1.2.1. The extension is in the Enrollee’s interest; and 2.11.5.6.1.2.2. There is a need for additional 2.11.5.6.1.2.2.1. There is a reasonable 2.11.5.6.1.2.2.2. Such outstanding 2.11.5.6.2. For expedited service authorization decisions, where the provider indicates or the Contractor determines that following the standard timeframe in Section

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 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 Title 22 CCR § 53261, and must: 2.11.5.5.1. Be produced in a manner, format, and language that can be easily understood; 2.11.5.5.2. Be made available in Threshold Languages, upon request; 2.11.5.5.3. Include information, in Threshold Languages about how to request translation services and alternative formats. Alternative formats shall include materials which can be understood by persons with limited English proficiency: and 2.11.5.5.4. In any written communication to a physician or other health care provider of a denial, delay or modification of a request, include the name and telephone number of the health care professional responsible for the denial, delay or modification. 2.11.5.6. The Contractor must make authorization decisions in the following timeframes: 2.11.5.6.1. For standard authorization decisions, provide notice as expeditiously as the Enrollee’s health condition requires, within five (5) working days from receipt of the information reasonably necessary to render a decision, and in all circumstances no later than fourteen (14) calendar days after receipt of the request for service, with a possible extension not to exceed fourteen (14) additional calendar days. Such extension shall only be allowed if: 2.11.5.6.1.1. The Enrollee or the Provider requests an extension, or 2.11.5.6.1.2. The Contractor can justify (to thethe satisfaction of DHCS and/or CMS upon request) that: 2.11.5.6.1.2.1. The extension is in the Enrollee’s interest; and 2.11.5.6.1.2.2. There is a need for additionaladditional information where: 2.11.5.6.1.2.2.1. There is a reasonablereasonable likelihood that receipt of such information would lead to approval of the request, if received; and 2.11.5.6.1.2.2.2. Such outstandingoutstanding information is reasonably expected to be received within fourteen (14) calendar days. 2.11.5.6.2. For expedited service authorization decisions, where the provider indicates or the Contractor determines that following the standard timeframe in Section 2.11.4.7.1 could seriously jeopardize the Enrollee’s life or health or ability to attain, maintain, or regain maximum function, the Contractor must make a decision and provide notice as expeditiously as the Enrollee’s health condition requires and no later than seventy-two (72) hours after receipt of the request for service, with a possible extension not to exceed fourteen (14) additional calendar days. Such extension shall only be allowed if: 2.11.5.6.2.1. The Enrollee or the provider requests an extension; or 2.11.5.6.2.2. The Contractor can justify (to DHCS and/or CMS upon request) that: 2.11.5.6.2.2.1. The extension is in the Enrollee’s interest; and 2.11.5.6.2.2.2. There is a need for additional information where: 2.11.5.6.2.2.2.1. There is a reasonable likelihood that receipt of such information would lead to approval of the request, if received; and 2.11.5.6.2.2.2.2. Such outstanding information is reasonably expected to be received within fourteen (14) calendar days. 2.11.5.6.3. In accordance with 42 C.F.R. §§ 438.3(i), 438.210(e), and 422.208, compensation to individuals or entities that conduct utilization management activities for the Contractor must not be structured so as to provide incentives for the individual or entity to deny, limit, or discontinue Medically Necessary Covered Services to any Enrollee.

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 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 Title 22 CCR § 53261, and must: 2.11.5.5.1. Be produced in a manner, format, and language that can be easily understood; 2.11.5.5.2. Be made available in Threshold Languages, upon request;; and 2.11.5.5.3. Include information, in Threshold Languages about how to request translation services and alternative formats. Alternative formats shall include materials which can be understood by persons with limited English proficiency: and 2.11.5.5.4. In any written communication to a physician or other health care provider of a denial, delay or modification of a request, include the name and telephone number of the health care professional responsible for the denial, delay or modification. 2.11.5.6. The Contractor must make authorization decisions in the following timeframes: 2.11.5.6.1. For standard authorization decisions, provide notice as expeditiously as the Enrollee’s health condition requires, within five (5) working days from receipt of the information reasonably necessary to render a decision, requires and in all circumstances no later than fourteen (14) calendar days after receipt of the request for service, with a possible extension not to exceed fourteen (14) additional calendar days. Such extension shall only be allowed if: 2.11.5.6.1.1. The Enrollee or the Provider requests an extension, or 2.11.5.6.1.2. The Contractor can justify (to thethe satisfaction of DHCS and/or CMS upon request) that: 2.11.5.6.1.2.1. The extension is in the Enrollee’s interest; and 2.11.5.6.1.2.2. There is a need for additional 2.11.5.6.1.2.2.1. There is a reasonable 2.11.5.6.1.2.2.2. Such outstanding 2.11.5.6.2. For expedited service authorization decisions, where the provider indicates or the Contractor determines that following the standard timeframe in Section 2.11.4.7.1 could seriously jeopardize the Enrollee’s life or health or ability to attain, maintain, or regain maximum function, the Contractor must make a decision and provide notice as expeditiously as the Enrollee’s health condition requires and no later than seventy-two (72) hours after receipt of the request for service, with a possible extension not to exceed fourteen (14) additional calendar days. Such extension shall only be allowed if: 2.11.5.6.2.1. The Enrollee or the provider requests an extension; or 2.11.5.6.2.2. The Contractor can justify (to DHCS and/or CMS upon request) that: 2.11.5.6.2.2.1. The extension is in the Enrollee’s interest; and 2.11.5.6.2.2.2. There is a need for additional 2.11.5.6.2.2.2.1. There is a reasonable 2.11.5.6.2.2.2.2. Such outstanding 2.11.5.6.3. In accordance with 42 C.F.R. §§ 438.3(i), 438.210(e), and 422.208, compensation to individuals or entities that conduct utilization management activities for the Contractor must not be structured so as to provide incentives for the individual or entity to deny, limit, or discontinue Medically Necessary Covered Services to any Enrollee.