Common use of Authorization or Denial of Covered Services Clause in Contracts

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.

Authorization or Denial of Covered Services. a. Contractor shall establish and adhere to written policies and procedures that for both the initial and continuing Service Authorization Requests. Contractor follows, and requires shall require its Participating Providers and Subcontractors to follow, adhere to established policies for the initial and continuing Service Authorization Requests. The procedures must require that any decision to deny a Service Authorization Request 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 mental, or oral health condition or disease disease, in accordance with 42 CFR §438.210.

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.

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 Requestsauthorizations of services as defined in OAR 410-141-0000. The procedures That procedure must require that any decision to deny a Service Authorization Request 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, health or mental or oral health condition or disease in accordance with 42 CFR 438.210.