Common use of Authorization of Services Clause in Contracts

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. a. The 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/PIHP 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 2. ) The Contractor LIP requests the extension; or, 3. ) The LME/PIHP justifies to the Department upon request: a) A. A need for additional information; and b) B. How the extension is in the Enrollee’s interest. c. In those cases for services requiring prior authorization in which Contractor LIP indicates, or LME/PIHP determines, that adherence to the standard timeframe could seriously jeopardize an a 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. A need for additional information; and b) 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. a. The 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/PIHP 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 2. or The Contractor LIP requests the extension; or 3. , The LME/PIHP justifies to the Department upon request: a) : A need for additional information; and b) and How the extension is in the Enrollee’s interest. c. . In those cases for services requiring prior authorization in which Contractor LIP indicates, or LME/PIHP determines, that adherence to the standard timeframe could seriously jeopardize an a 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. or The LME/PIHP justifies to the Department upon request: a) : A need for additional information; and b) and 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 EnrolleeXxxxxxxx’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. 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 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 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 EnrolleeXxxxxxxx’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. 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. or The Contractor CONTRACTOR requests the extension; or 3. or The LME/PIHP justifies to the Department upon request: a) : A need for additional information; and b) and How the extension is in the Enrollee’s interest. c. . In those cases for services requiring prior authorization in which Contractor 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. or The LME/PIHP justifies to the Department upon request: a) : A need for additional information; and b) and 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. For appeal information, please refer to the LME/PIHP Provider Operations Manual. In conducting prior authorization, LME/PIHP shall not require CONTRACTOR to resubmit any data or documents previously provided to LME/PIHP for the Enrollee’s presently authorized services.

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 CONTRACTOR requests the extension; orand, 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 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 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 2. The CONTRACTOR requests the extension; and, 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. 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 EnrolleeXxxxxxxx’s attending physician or ordering provider of the availability of a peer to peer conversation, to be conducted within one business day. f. Upon the denial of a requested authorization and peer to peer conversation deadline, the LME/PIHP first 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 CONTRACTOR to resubmit any data or documents previously provided to LME/PIHP for the Enrollee’s presently authorized services.

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 CONTRACTOR requests the extension; orand, 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 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 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 2. The CONTRACTOR requests the extension; and, 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. 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. f. Upon the denial of a requested authorization and peer to peer conversation deadline, the LME/PIHP first 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 CONTRACTOR to resubmit any data or documents previously provided to LME/PIHP for the Enrollee’s presently authorized services.

Authorization of Services. a. A. The LMEBH I/PIHP DD Tailored Plan shall determine medical necessity for those services requiring prior authorization as set forth in Controlling Authority, including DMA DHB Clinical Coverage Policies. b. For B. Unless otherwise required by Controlling Authority, for those services requiring prior authorization, the LMEBH I/PIHP DD Tailored Plan 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. i. The Enrollee Member requests the extension; or 2ii. The Contractor requests the extension; or 3iii. The LMEBH I/PIHP DD Tailored Plan justifies to the Department upon request: a) A need for additional information; and b) How the extension is in the EnrolleeMember’s interest. c. C. In those cases for services requiring prior authorization in which Contractor indicates, or LMEBH I/PIHP DD Tailored Plan determines, that adherence to the standard timeframe could seriously jeopardize an Enrolleea Member’s life or health or ability to attain, maintain, or regain maximum function, including but not limited to psychiatric inpatient hospitalization services, LMEthe BH I/PIHP DD Tailored Plan shall issue a decision to approve or deny a service within three (3) 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. i. The Enrollee Member requests the extension; or 2ii. The LMEBH I/PIHP DD Tailored Plan justifies to the Department upon request: a) A need for additional information; and b) How the extension is in the EnrolleeMember’s interest. d. D. For those services requiring prior authorization, the LMEBH I/PIHP DD Tailored Plan shall permit retroactive authorization of such services in instances where the Enrollee Member has been retroactively enrolled in the Medicaid program or in the LMEBH I/PIHP DD Tailored Plan program, or where the Enrollee Member has primary insurance which has not yet paid or denied its claim. Retroactive authorizations include requests for deceased EnrolleesMembers. The request for authorization must be submitted within ninety (90) days of primary denial or notice of enrollment. e. E. Upon the denial of a requested authorization, the LMEBH I/PIHP DD Tailored Plan shall inform EnrolleeMember’s attending physician or ordering provider of the availability of a peer to peer conversation, to be conducted within one (1) business day. F. For appeal information, please refer to the BH I/DD Tailored Plan Provider Manual. G. In conducting prior authorization, BH I/DD Tailored Plan shall not require Contractor to resubmit any data or documents previously provided to BH I/DD Tailored Plan for the Member’s presently authorized services. H. CHAPTER 58 REQUIREMENTS. Pursuant to G.S. § 58-3-200(c), BH I/DD Tailored Plan shall not retract a determination that services, supplies or other items are covered under the BH I/DD Tailored Plan Benefit Plan after the services, supplies, or other items have been provided, nor shall BH I/DD Tailored Plan reduce payments for services, supplies or other items furnished in reliance on such a determination, except however that the BH I/DD Tailored Plan may retract such determination if its determination was based on a material misrepresentation about the Member’s health condition that was knowingly made by the Member or the provider of the service, supply or other item.

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 CONTRACTOR requests the extension; orand, 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 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 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 2. The CONTRACTOR requests the extension; and, 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. 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. f. Upon the denial of a requested authorization and peer to peer conversation deadline, the LME/PIHP first 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 CONTRACTOR to resubmit any data or documents previously provided to LME/PIHP for the Enrollee’s presently authorized services.

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; orand, 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 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 2. The Contractor requests the extension; and, 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. 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 EnrolleeXxxxxxxx’s attending physician or ordering provider of the availability of a peer to peer conversation, to be conducted within one business day. f. Upon the denial of a requested authorization and peer to peer conversation deadline, the LME/PIHP first 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 Contractor to resubmit any data or documents previously provided to LME/PIHP for the Enrollee’s presently authorized services.