Common use of Authorization of Services Clause in Contracts

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. 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 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.