Common use of Authorization of Services Clause in Contracts

Authorization of Services. Except for unmanaged visits that do not require prior authorization, the LME/PIHP shall determine medical necessity for those services requiring prior authorization as set forth in Controlling Authority, including DMA Clinical Coverage Policies. For those services requiring prior authorization, the LME/PHIP 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: The Enrollee requests the extension; or The LIP requests the extension; or, The LME/PIHP justifies to the Department upon request: A need for additional information; and How the extension is in the Enrollee’s interest. In those cases for services requiring prior authorization in which LIP indicates, or LME/PIHP determines, that adherence to the standard timeframe could seriously jeopardize a Enrollee’ 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 additional calendar days if: The Enrollee requests the extension; or The LME/PIHP justifies to the Department upon request: A need for additional information; and How the extension is in the Enrollee’s interest. 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. Upon the denial of a requested authorization, the LME/PIHP shall inform Xxxxxxxx’s attending physician or ordering provider of the availability of a peer to peer conversation, to be conducted within one business day. For appeal information, please refer to the LME/PIHP Provider Operations Manual. In conducting prior authorization, LME/PIHP shall not require LIP to resubmit any data or documents previously provided to LME/PIHP for the Enrollee’s presently authorized services.

Authorization of Services. Except for unmanaged visits that do not require prior authorization, the 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/PHIP 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 or 2. The LIP Contractor requests the extension; or, and, 3. The LME/PIHP justifies to the Department upon request: : a) A need for additional information; and and b) How the extension is in the Enrollee’s interest. . c. In those cases for services requiring prior authorization in which LIP Contractor indicates, or LME/PIHP determines, that adherence to the standard timeframe could seriously jeopardize a 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 twenty-four (24) hours 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 or 2. The Contractor requests the extension; and, 3. The LME/PIHP justifies to the Department upon request: : a) A need for additional information; and 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 Xxxxxxxx’s attending physician or ordering provider of the availability of a peer to peer conversation, to be conducted within one business day. For appeal information. f. Upon the denial of a requested authorization and peer to peer conversation deadline, please refer to the LME/PIHP Provider Operations Manualfirst level of appeal shall permit the Enrollee or Contractor to submit additional information to a clinical peer reviewer with the LME/PIHP. The LME/PIHP clinical peer shall determine the correctness of the LME/PIHP’s decision to deny the requested authorization. The LME/PIHP clinical peer shall be a clinical peer to the Xxxxxxxx’s attending physician or ordering provider, hold an active unrestricted license, be board certified, not be involved in the original LME/PIHP decision and not subordinate to the individual who made the original LME/PIHP decision. In instances of a request for authorization of urgent services, the LME/PIHP shall provide verbal notification of an appeal decision within seventy-two (72) hours of the request and shall provide written notification of an appeal decision within three (3) days of the verbal notification. In instance of a request for authorization of non-urgent services, the LME/PIHP shall provide written notification of an appeal decision within thirty (30) days. g. In conducting prior authorization, LME/PIHP shall not require LIP Contractor to resubmit any data or documents previously provided to LME/PIHP for the Enrollee’s presently authorized services.

Authorization of Services. Except for unmanaged visits that do not require prior authorization, the 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/PHIP 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 or 2. The LIP Contractor requests the extension; or, 3. The LME/PIHP justifies to the Department upon request: : a) A need for additional information; and and b) How the extension is in the Enrollee’s interest. . c. In those cases for services requiring prior authorization in which LIP Contractor indicates, or LME/PIHP determines, that adherence to the standard timeframe could seriously jeopardize a 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 or 2. The LME/PIHP justifies to the Department upon request: : a) A need for additional information; and 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 XxxxxxxxEnrollee’s attending physician or ordering provider of the availability of a peer to peer conversation, to be conducted within one business day. For appeal information, please refer to the LME/PIHP Provider Operations Manual. In conducting prior authorization, LME/PIHP shall not require LIP to resubmit any data or documents previously provided to LME/PIHP for the Enrollee’s presently authorized services.

Authorization of Services. a. Except for unmanaged visits that do not require prior authorization, 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/PHIP 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 or 2) The LIP requests the extension; or, , 3) The LME/PIHP justifies to the Department upon request: : A. A need for additional information; and and B. How the extension is in the Enrollee’s interest. . c. In those cases for services requiring prior authorization in which LIP indicates, or LME/PIHP determines, that adherence to the standard timeframe could seriously jeopardize a Enrollee’ 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 additional calendar days if: : 1) The Enrollee requests the extension; or or 2) The LME/PIHP justifies to the Department upon request: : A. A need for additional information; and 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 XxxxxxxxEnrollee’s attending physician or ordering provider of the availability of a peer to peer conversation, to be conducted within one business day. For appeal information, please refer to the LME/PIHP Provider Operations Manual. In conducting prior authorization, LME/PIHP shall not require LIP to resubmit any data or documents previously provided to LME/PIHP for the Enrollee’s presently authorized services.

Authorization of Services. Except for unmanaged visits that do not require prior authorization, the 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/PHIP 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 or 2. The LIP CONTRACTOR requests the extension; or, and, 3. The LME/PIHP justifies to the Department upon request: : a) A need for additional information; and and b) How the extension is in the Enrollee’s interest. . c. In those cases for services requiring prior authorization in which LIP CONTRACTOR indicates, or LME/PIHP determines, that adherence to the standard timeframe could seriously jeopardize a 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 twenty-four (24) hours 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 or 2. The CONTRACTOR requests the extension; and, 3. The LME/PIHP justifies to the Department upon request: : a) A need for additional information; and 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 XxxxxxxxEnrollee’s attending physician or ordering provider of the availability of a peer to peer conversation, to be conducted within one business day. For appeal information. f. Upon the denial of a requested authorization and peer to peer conversation deadline, please refer to the LME/PIHP Provider Operations Manualfirst level of appeal shall permit the Enrollee or CONTRACTOR to submit additional information to a clinical peer reviewer with the LME/PIHP. The LME/PIHP clinical peer shall determine the correctness of the LME/PIHP’s decision to deny the requested authorization. The LME/PIHP clinical peer shall be a clinical peer to the Enrollee’s attending physician or ordering provider, hold an active unrestricted license, be board certified, not be involved in the original LME/PIHP decision and not subordinate to the individual who made the original LME/PIHP decision. In instances of a request for authorization of urgent services, the LME/PIHP shall provide verbal notification of an appeal decision within seventy-two (72) hours of the request and shall provide written notification of an appeal decision within three (3) days of the verbal notification. In instance of a request for authorization of non-urgent services, the LME/PIHP shall provide written notification of an appeal decision within thirty (30) days. g. In conducting prior authorization, LME/PIHP shall not require LIP CONTRACTOR to resubmit any data or documents previously provided to LME/PIHP for the Enrollee’s presently authorized services.

Authorization of Services. Except for unmanaged visits that do not require prior authorization, the 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/PHIP 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 or 2. The LIP CONTRACTOR requests the extension; or, 3. The LME/PIHP justifies to the Department upon request: : a) A need for additional information; and and b) How the extension is in the Enrollee’s interest. . c. In those cases for services requiring prior authorization in which LIP CONTRACTOR indicates, or LME/PIHP determines, that adherence to the standard timeframe could seriously jeopardize a 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 or 2. The LME/PIHP justifies to the Department upon request: : a) A need for additional information; and 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 Xxxxxxxx’s attending physician or ordering provider of the availability of a peer to peer conversation, to be conducted within one business day. For appeal information, please refer to the LME/PIHP Provider Operations Manual. In conducting prior authorization, LME/PIHP shall not require LIP to resubmit any data or documents previously provided to LME/PIHP for the Enrollee’s presently authorized services.

Authorization of Services. Except for unmanaged visits that do not require prior authorization, the 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/PHIP 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 or 2. The LIP CONTRACTOR requests the extension; or, and, 3. The LME/PIHP justifies to the Department upon request: : a) A need for additional information; and and b) How the extension is in the Enrollee’s interest. . c. In those cases for services requiring prior authorization in which LIP CONTRACTOR indicates, or LME/PIHP determines, that adherence to the standard timeframe could seriously jeopardize a 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 twenty- four (24) hours 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 or 2. The CONTRACTOR requests the extension; and, 3. The LME/PIHP justifies to the Department upon request: : a) A need for additional information; and 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 XxxxxxxxEnrollee’s attending physician or ordering provider of the availability of a peer to peer conversation, to be conducted within one business day. For appeal information. f. Upon the denial of a requested authorization and peer to peer conversation deadline, please refer to the LME/PIHP Provider Operations Manualfirst level of appeal shall permit the Enrollee or CONTRACTOR to submit additional information to a clinical peer reviewer with the LME/PIHP. The LME/PIHP clinical peer shall determine the correctness of the LME/PIHP’s decision to deny the requested authorization. The LME/PIHP clinical peer shall be a clinical peer to the Enrollee’s attending physician or ordering provider, hold an active unrestricted license, be board certified, not be involved in the original LME/PIHP decision and not subordinate to the individual who made the original LME/PIHP decision. In instances of a request for authorization of urgent services, the LME/PIHP shall provide verbal notification of an appeal decision within seventy-two (72) hours of the request and shall provide written notification of an appeal decision within three (3) days of the verbal notification. In instance of a request for authorization of non-urgent services, the LME/PIHP shall provide written notification of an appeal decision within thirty (30) days. g. In conducting prior authorization, LME/PIHP shall not require LIP CONTRACTOR to resubmit any data or documents previously provided to LME/PIHP for the Enrollee’s presently authorized services.

Authorization of Services. Except for unmanaged visits that do not require prior authorization, the The LME/PIHP shall determine medical necessity for those services requiring prior authorization as set forth in Controlling Authority, including DMA Clinical Coverage Policies. For those services requiring prior authorization, the LME/PHIP 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: The Enrollee requests the extension; or The LIP CONTRACTOR requests the extension; or, or The LME/PIHP justifies to the Department upon request: A need for additional information; and How the extension is in the Enrollee’s interest. In those cases for services requiring prior authorization in which LIP CONTRACTOR indicates, or LME/PIHP determines, that adherence to the standard timeframe could seriously jeopardize a 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: The Enrollee requests the extension; or The LME/PIHP justifies to the Department upon request: A need for additional information; and How the extension is in the Enrollee’s interest. 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. Upon the denial of a requested authorization, the LME/PIHP shall inform XxxxxxxxEnrollee’s attending physician or ordering provider of the availability of a peer to peer conversation, to be conducted within one business day. For appeal information, please refer to the LME/PIHP Provider Operations Manual. In conducting prior authorization, LME/PIHP shall not require LIP CONTRACTOR to resubmit any data or documents previously provided to LME/PIHP for the Enrollee’s presently authorized services.

Authorization of Services. Except for unmanaged visits that do not require prior authorization, the 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/PHIP 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 or 2. The LIP CONTRACTOR requests the extension; or, and, 3. The LME/PIHP justifies to the Department upon request: : a) A need for additional information; and and b) How the extension is in the Enrollee’s interest. . c. In those cases for services requiring prior authorization in which LIP CONTRACTOR indicates, or LME/PIHP determines, that adherence to the standard timeframe could seriously jeopardize a 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 twenty-four (24) hours 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 or 2. The CONTRACTOR requests the extension; and, 3. The LME/PIHP justifies to the Department upon request: : a) A need for additional information; and 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 Xxxxxxxx’s attending physician or ordering provider of the availability of a peer to peer conversation, to be conducted within one business day. For appeal information. f. Upon the denial of a requested authorization and peer to peer conversation deadline, please refer to the LME/PIHP Provider Operations Manualfirst level of appeal shall permit the Enrollee or CONTRACTOR to submit additional information to a clinical peer reviewer with the LME/PIHP. The LME/PIHP clinical peer shall determine the correctness of the LME/PIHP’s decision to deny the requested authorization. The LME/PIHP clinical peer shall be a clinical peer to the Enrollee’s attending physician or ordering provider, hold an active unrestricted license, be board certified, not be involved in the original LME/PIHP decision and not subordinate to the individual who made the original LME/PIHP decision. In instances of a request for authorization of urgent services, the LME/PIHP shall provide verbal notification of an appeal decision within seventy-two (72) hours of the request and shall provide written notification of an appeal decision within three (3) days of the verbal notification. In instance of a request for authorization of non-urgent services, the LME/PIHP shall provide written notification of an appeal decision within thirty (30) days. g. In conducting prior authorization, LME/PIHP shall not require LIP CONTRACTOR to resubmit any data or documents previously provided to LME/PIHP for the Enrollee’s presently authorized services.