Common use of Benefits Management Program Clause in Contracts

Benefits Management Program. The Benefits Management Program applies utilization man- agement and case management principles to assist Members and providers in identifying the most appropriate and cost- effective way to use the Benefits provided under this health plan. The Benefits Management Program includes prior authoriza- tion requirements for inpatient admissions, selected inpatient and outpatient services, office-administered injectable drugs, and home-infusion-administered drugs, as well as emergency admission notification, and inpatient utilization management. The program also includes Member services such as, dis- charge planning, case management and, palliative care ser- vices. The “Prior Authorization List” is a list of medical services and drugs that require prior authorization. Members are en- couraged to work with their providers to obtain prior authori- zation. Members and providers may call Customer Service at the number provided on the back page of this Evidence of Coverage to inquire about the need for prior authorization. Providers may also access the Prior Authorization List on the provider website. The following sections outline the Member’s responsibilities under the Benefits Management Program. The Benefits Man- agement Program applies to all Members. Prior authorization allows the Member and provider to verify with Blue Shield that (1) the proposed services are a Benefit of the Member’s plan, (2) the proposed services are Medical- ly Necessary, and (3) the proposed setting is clinically appro- priate. The prior authorization process also informs the Member and provider when Benefits are limited to services rendered by a Participating Provider (See the Summary of Benefits). The Member or provider should call Customer Service at the number provided on the back page of this Evidence of Cov- erage for prior authorization of non-emergency medical Hos- pital admissions and all medical services and drugs included in the Prior Authorization List (except for radiological and nuclear imaging procedures). Prior authorization for radiolog- ical and nuclear imaging procedures and Mental Health Ser- vices is addressed separately in the following Prior Authori- zation for Radiological and Nuclear Imaging Procedures and Prior Authorization for Mental Health Hospital Admissions and Non-routine Outpatient Services sections. A decision will be made on all requests for prior authoriza- tion within five business days from receipt of the request. The treating provider will be notified of the decision within 24 hours and written notice will be sent to the Member and pro- vider within two business days of the decision. For urgent services when the routine decision making process might seriously jeopardize the life or health of a Member or when the Member is experiencing severe pain, a decision will be rendered as soon as possible to accommodate the Member’s condition, not to exceed 72 hours from receipt of the request. (See the Outpatient Prescription Drug Benefits section for specific information about prior authorization for outpatient prescription drugs). Failure to obtain prior authorization from Blue Shield may increase the Member’s share of the cost for Covered Services or may result in non-payment or denial of coverage by Blue Shield. Prior authorization is required for radiological and nuclear imaging procedures. The Member or provider should call 0- 000-000-0000 for prior authorization of the following radio- logical and nuclear imaging procedures when performed within California on an outpatient, non-emergency basis:

Benefits Management Program. The Benefits Management Program applies utilization man- agement and case management principles to assist Members and providers in identifying the most appropriate and cost- effective way to use the Benefits provided under this health plan. The Benefits Management Program includes prior authoriza- tion requirements for inpatient admissions, selected inpatient and outpatient services, office-administered injectable drugs, and home-infusion-administered drugs, as well as emergency admission notification, and inpatient utilization management. The program also includes Member services such as, dis- charge planning, case management and, palliative care ser- vices. The “Prior Authorization List” is a list of medical services and drugs that require prior authorization. Members are en- couraged to work with their providers to obtain prior authori- zation. Members and providers may call Customer Service at the number provided on the back page of this Evidence of Coverage to inquire about the need for prior authorization. Providers may also access the Prior Authorization List on the provider website. The following sections outline the Member’s responsibilities under the Benefits Management Program. The Benefits Man- agement Program applies to all Members. Prior authorization allows the Member and provider to verify with Blue Shield that (1) the proposed services are a Benefit of the Member’s plan, (2) the proposed services are Medical- ly Necessary, and (3) the proposed setting is clinically appro- priate. The prior authorization process also informs the Member and provider when Benefits are limited to services rendered by a Participating Provider (See the Summary of Benefits). The Member or provider should call Customer Service at the number provided on the back page of this Evidence of Cov- erage for prior authorization of non-emergency medical Hos- pital admissions and all medical services and drugs included in the Prior Authorization List (except for radiological and nuclear imaging procedures). Prior authorization for radiolog- ical radio- logical and nuclear imaging procedures and Mental Health Ser- vices Services is addressed separately in the following Prior Authori- zation Au- thorization for Radiological and Nuclear Imaging Procedures Proce- dures and Prior Authorization for Mental Health Hospital Admissions and Non-routine Outpatient Services sections. A decision will be made on all requests for prior authoriza- tion within five business days from receipt of the request. The treating provider will be notified of the decision within 24 hours and written notice will be sent to the Member and pro- vider provider within two business days of the decision. For urgent services when the routine decision making process might seriously jeopardize the life or health of a Member or when the Member is experiencing severe pain, a decision will be rendered as soon as possible to accommodate the Member’s condition, not to exceed 72 hours from receipt of the request. (See the Outpatient Prescription Drug Benefits section for specific information about prior authorization for outpatient prescription drugs). Failure to obtain prior authorization from Blue Shield may increase the Member’s share of the cost for Covered Services or may result in non-payment or denial of coverage by Blue Shield. Prior authorization is required for radiological and nuclear imaging procedures. The Member or provider should call 0- 000-000-0000 for prior authorization of the following radio- logical and nuclear imaging procedures when performed within California on an outpatient, non-emergency basis: