Authorization or Denial of Covered Services a. Contractor shall draft a Service Authorization Handbook that sets forth Contractor’s written policies and procedures that comply with 42 CFR § 438.210 and OAR 000-000-00000 to ensure consistent application of review criteria for authorization decisions. Contractor shall ensure processes allow for consultation with a requesting Provider for medical services when necessary and that processes are in place for both initial and continuing Service Authorization Requests. Such policies and procedures must include, without limitation: (i) those procedures that must be followed in order to obtain initial and continuing Service Authorizations, and (ii) the requirement that any decision to deny a Service Authorization Request or to authorize a service in an amount, duration, or scope that is less than requested, be made by a Health Care Professional who has appropriate clinical expertise in treating the Member’s physical, Behavioral, or Oral Health condition or disease, as applicable. Contractor shall require its Participating Providers and Subcontractors to adhere to the policies and procedures set forth in the Service Authorization Handbook.
Authorization or Denial of Covered Services a. Contractor shall establish written procedures that Contractor follows, and requires Participating Providers and Subcontractors to follow, for the initial and continuing Service Authorization Requests. The procedures must require that any decision to deny a Service Authorization Request or to authorize a service in an amount, duration or scope that is less than requested, be made by a Health Care Professional who has appropriate clinical expertise in treating the Member’s physical, mental or oral health condition or disease in accordance with 42 CFR 438.210.
b. Contractor may require Members and Subcontractors to obtain authorization for Covered Services from Contractor, except to the extent Prior Authorization is prohibited by OHP rules or elsewhere in this Contract.
c. Contractor may not require Members to obtain the approval of a Primary Care Physician in order to gain access to mental health or Substance Use Disorders Assessment and Evaluation services. Members may refer themselves to mental health and Substance Use Disorders services available from the Provider Network.
d. Contractor shall ensure the provision of sexual abuse exams without Prior Authorization.
e. Contractor shall have in effect mechanisms to ensure consistent application of review criteria for authorization decisions, taking into account applicable clinical practice guidelines, and consults with the requesting Provider when appropriate.
f. For standard Service Authorization Requests, Contractor shall provide notice as expeditiously as the Member’s health or mental health condition requires, not to exceed 14 calendar days following receipt of the request for service, with a possible extension of 14 additional days if the Member or Provider requests extension, or if the Contractor justifies a need for additional information and how the extension is in the Member’s interest. If Contractor extends the time frame, Contractor shall provide the Member and Provider with a written notice of the reason for the decision to extend the timeframe and inform the Member of the right to file a Grievance if he or she disagrees with that decision. When a decision is not reached regarding a Service Authorization Request within the timeframes specified above, Contractor shall issue a Notice of Action (NOA) to the Provider and Member, or Member Representative, consistent with Exhibit I, Grievance System.
g. If a Member or Provider suggests, or Contractor determines, that following the standard timeframes...
Authorization or Denial of Covered Services. The terms and conditions of Section 3, Exhibit B, Part 2 in the Medicaid Contract are incorporated by reference and have the same force and effect as though they are fully set forth herein.
Authorization or Denial of Covered Services.
a. Contractor shall draft a Service Authorization Handbook that sets forth Contractor’s written policies and procedures that comply with 42 CFR § 438.210 and OAR 000-000-0000 to ensure consistent application of review criteria for authorization decisions. Contractor shall ensure processes allow for consultation with a requesting Provider for medical services when necessary
Authorization or Denial of Covered Services a. The terms and conditions of Paragraph a of Section 3, Exhibit B, Part 2 in the Medicaid Contract are incorporated by reference and have the same force and effect as though they are fully set forth herein.
b. The terms and conditions of Paragraph b of Section 3, Exhibit B, Part 2 in the Medicaid Contract are incorporated by reference and have the same force and effect as though they are fully set forth herein except for Subparagraph (10), which is provided below.
Authorization or Denial of Covered Services a. Contractor shall establish written procedures that Contractor follows, and requires Participating Providers to follow, for the initial and continuing authorizations of services as defined in OAR 410-141-0000. That procedure must require that any decision to deny a service authorization request or to authorize a service in an amount, duration or scope that is less than requested, be made by a Health Care Professional who has appropriate clinical expertise in treating the Member’s health or mental health condition or disease in accordance with 42 CFR 438.210.
b. Contractor may require Members and Subcontractors to obtain authorization for Covered Services from Contractor, except to the extent prior authorization is not required in OAR 410- 141-2420 or elsewhere in this Statement of Work.
Authorization or Denial of Covered Services a. Contractor shall establish and adhere todraft a Service Authorization Handbook that sets forth Contractor’s written policies and procedures that comply with 42 CFR §438.210 and OAR 410-141-3225 to ensure consistent application of review criteria for authorization decisions. Contractor shall ensure processes allow for consultation with a requesting Provider for medical services when necessary and that processes are in place for both the initial and continuing Service Authorization Requests. Contractor shall require its Participating Providers and Subcontractors to adhere to establishedSuch policies for Service Authorization Requests. Theand procedures must requireinclude, without limitation: (i) those procedures that must be followed in order to obtain initial and continuing Service Authorizations, and (ii) the requirement that any decision to deny a Service Authorization Request or to authorize a service in an amount, duration, or scope that is less than requested, be made by a Health Care Professional who has appropriate clinical expertise in treating the Member’s physical, mentalbehavioral, or oral healthOral Health condition or disease in accordance with 42 CFR §438.210.
b. Contractor maymust require Membersits Participating Providers and Subcontractors to obtain authorization Contract # (XXXXXX) CCO 2.0 Contract Template Exhibit B – Statement of Work – Part 2 - Covered and Non-Covered Services Page 26 of 358 for Covered Services from Contractor, except to the extent Prioradhere to the policies and procedures set forth in the Service Authorization is prohibited by OHP rules or elsewhere in this ContractHandbook.
c. Contractor may not require Members to obtain the approval of a Primary Care Physician in order to gain access to behavioral health Assessment and Evaluation services. Members may refer themselves to behavioral health services available from the Provider Network.
d. Contractor shall permit Members to refer themselves to a Traditional Health Worker for services within the scope of practice defined in Oregon Administrative Rule.
e. Contractor shall ensure the provision of sexual abuse exams without Prior Authorization.
Authorization or Denial of Covered Services a. Contractor shall establish and adhere to written policies and procedures for both the initial and continuing Service Authorization Requests. Contractor shall require its Participating Providers and Subcontractors to adhere to established policies for Service Authorization Requests. The procedures must require that any decision to deny a Service Authorization Request, or to authorize a service in an amount, duration or scope that is less than requested, be made by a Health Care Professional who has appropriate clinical expertise in treating the Member’s physical, mental, or oral health condition or disease, in accordance with 42 CFR §438.210.
b. Contractor may require Members and Subcontractors to obtain authorization for Covered Services from Contractor, except to the extent Prior Authorization is prohibited by OHP rules or elsewhere in this Contract.
c. Contractor may not require Members to obtain the approval of a Primary Care Physician in order to gain access to Behavioral Health assessment and evaluation services. Members may refer themselves to Behavioral Health services available from the Provider Network.
d. Contractor shall permit Members to refer themselves to a Traditional Health Worker for services within the scope of practice defined in Oregon Administrative Rule.
e. Contractor shall ensure the provision of sexual abuse exams without Prior Authorization.
f. Contractor shall have in effect mechanisms to ensure consistent application of review criteria for authorization decisions, taking into account applicable clinical practice guidelines, and consults with the requesting Provider when appropriate.
g. Contractors must permit out-of-network IHCPs to refer a CCO-enrolled Indian to a network Provider for Covered Services, as required by 42 CFR §438.14(b)(6).
h. For standard Service Authorization Requests, Contractor shall provide notice to the requesting Provider as expeditiously as the Member’s health or mental health condition requires, not to exceed fourteen (14) days following receipt of the request for service, with a possible extension of fourteen (14) additional days if the Member or Provider requests extension, or if the Contractor justifies a need for additional information and can demonstrate that the extension is in the Member’s interest. If Contractor extends the time frame, Contractor shall provide the Member and Provider with a written notice of the reason for the decision to extend the timeframe and inform the Member of the right ...
