Common use of Benefit Determinations; Practice Guidelines Clause in Contracts

Benefit Determinations; Practice Guidelines. ‌ Insurer shall consult with the requesting Provider when making benefit determinations, as appropriate. Insurer shall follow written policies and procedures and practice guidelines, for making benefit determinations, including processing requests for initial and continuing authorization for services. Insurer shall adopt practice guidelines: a. That are based on valid, reliable clinical evidence of Providers in the relevant field; b. Consider the needs of Enrollees; and c. In consultation with contracting health care professionals. Insurer shall review and periodically update its practice guidelines, as appropriate. Decisions related to utilization management, Enrollee education, coverage of services and other relevant areas shall be consistent with Insurer’s adopted practice guidelines. Insurer shall provide any practice guidelines used for the Plan to Enrollees, potential Enrollees and network Providers, upon request.

Benefit Determinations; Practice Guidelines. ‌ Insurer shall consult with the requesting Provider when making benefit determinations, as appropriate. Insurer shall follow written policies and procedures and practice guidelines, for making benefit determinations, including processing requests for initial and continuing authorization for services. Insurer shall adopt practice guidelines: a. That are based on valid, reliable clinical evidence of Providers in the relevant field; b. Consider the needs of Enrollees; and c. In consultation with contracting health care professionals. Insurer shall review and periodically update its practice guidelines, as appropriate. Decisions related to utilization management, Enrollee education, coverage of services services, and other relevant areas shall be consistent with Insurer’s adopted practice guidelines. Insurer shall provide any practice guidelines used for the Plan to Enrollees, potential Enrollees Enrollees, and network Providers, upon request.