Covered Services Subject to Utilization Management Sample Clauses

Covered Services Subject to Utilization Management. The following Utilization Management requirements must be met to qualify for benefits: A. Hospital Inpatient Services All elective inpatient hospital admissions (except for maternity and emergency admissions) require prior authorization. The provider must contact Evergreen (or, on the Member’s behalf, have the provider contact Evergreen) at least five (5) business days prior to an elective or scheduled admission to the hospital. If the admission cannot be scheduled in advance because it is not feasible to delay the admission for five (5) business days due to the Member’s medical condition, Evergreen must receive notification of the admission as soon as possible but in any event within forty−eight (48) hours following the beginning of the admission or by the end of the first business day following the beginning of the admission, whichever is later. Note the following: 1. Benefits for inpatient ancillary services (such as but not limited to radiology and laboratory) will not be denied solely based on the fact that the denial of the hospitalization day was appropriate. Instead, a denial of inpatient ancillary services shall be based on the Medical Necessity of the specific ancillary service. In determining the Medical Necessity of an ancillary service performed on a denied hospitalization day, consideration shall be given to the necessity of providing the ancillary service in the acute setting for each day in question. 2. For emergency admissions, Evergreen may not render an adverse decision solely because Evergreen was not notified of the emergency admission within the prescribed period of time after that admission if the Member’s condition prevented the hospital from determining the Member’s insurance status or Evergreen’s emergency admission requirements. B. Inpatient Mental Health and Substance Abuse Services Evergreen must be contacted for prior authorization at least five (5) business days prior to an elective or scheduled admission to the hospital. If the admission cannot be scheduled in advance because care is required immediately due to the Member’s condition, Evergreen must receive notification of the admission as soon as possible but in any event within forty−eight