Enhancement of Prior Authorization. The Contractor is required to collaborate with a member’s treating provider to ensure access to appropriate and efficient use of services that are medically necessary and of high quality. An anticipated outcome of this activity is greater member satisfaction resulting in fewer appeals that result in a Fair Hearing. In addition, the Contractor must demonstrate as required by the Rhode Island Department of Health, Rule and Regulations for the Utilization Review of Health Care Services (R23-17-.12-UR) Section 4.1.4 and NCQA Accreditation Standards, a reasonable attempt to collaborate with the provider to obtain sufficient information as part of the prior authorization decision. If the Contractor is unable to render a determination because of insufficient information, it must demonstrate that it has made every attempt to notify the patient and provider of the type of specific information that is needed in order to make such a decision. The Contractor is required to engage in a collaborative process between the Contractor and the treating provider. The initial authorization conversation between the Contractor and the treating provider shall include the following: • Ongoing dialogue and sharing of information as needed to obtain the necessary information to make an informed decision. For example, the provision of evidence based clinical guidelines and/or criteria to the treating provider that is pertinent to the specific utilization review. • As appropriate, the use of the allowed fifteen (15) day extension for receipt of additional and needed information for non-urgent cases and seventy-two (72) hours extension for urgent and emergency cases
Appears in 5 contracts
Samples: Medicaid Program Agreement, Medicaid Rite Smiles Program Agreement, Medicaid Rite Smiles Program Agreement
