Failure to Obtain Prior Authorization Sample Clauses

Failure to Obtain Prior Authorization. The Insured’s Physician must initiate all requests for Prior Authorization. If a Physician or Insured fails to follow the Plan’s procedures for filing a request for Prior Authorization (Pre-Service Claim), the Insured shall be notified of the failure and the proper procedures to be followed in order to obtain Prior Authorization. The Insured’s request for Prior Authorization must be received by an employee or by the department of the Plan customarily responsible for handling benefit matters. The original request must specifically name the Insured, the specific medical condition or symptom and the specific treatment, service or product for which approval is requested. The Insured notification of correct Prior Authorization procedures from the Plan shall be provided as soon as possible, but not later than five (5) days (twenty-four (24) hours in the case of an Urgent Care Claim) following the Plan’s receipt of the Insured’s original request. Notification by SHL may be oral unless specifically requested in writing by the Insured.
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Failure to Obtain Prior Authorization. The Member’s Physician must initiate all requests for Prior Authorization. If a Physician or Member fails to follow the Plan’s procedures for filing a request for Prior Authorization (Pre-Service Claim), the Member shall be notified of the failure and the proper procedures to be followed in order to obtain Prior Authorization. The Member’s request for Prior Authorization must be received by an employee or by the department of the Plan customarily responsible for handling benefit matters. The original request must specifically name the Member, the specific medical condition or symptom and the specific treatment, service or product for which approval is requested. The Member notification of correct Prior Authorization procedures from the Plan shall be provided as soon as possible, but not later than five (5) days (twenty-four (24) hours in the case of an Urgent Care Claim) following the Plan’s receipt of the Member’s original request. Notification by HPN may be oral unless specifically requested in writing by the Member.
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Failure to Obtain Prior Authorization. If the Member, the Member’s provider, or other appropriate party, as identified above, does not obtain Prior Authorization, The Plan will conduct a retrospective review after the claims have been submitted. If it is determined that the services were not Medically Necessary, were Experimental/Investigational/Unproven, were not performed in the appropriate treatment setting, or did not otherwise meet the terms and conditions of the Contract, the Member may be responsible for the full cost of the services. Length of Stay/Service Review Length of stay/Concurrent service review is not a guarantee of Benefits. Actual availability of Benefits is subject to eligibility and the other terms, conditions, limitations and Exclusions under this Contract. Upon completion of the inpatient or emergency admission review, Blue Cross and Blue Shield of Montana will send a letter to the Member, the Member’s provider, behavioral health practitioner and/or Hospital or facility with a determination on the approved length of service or length of stay. An extension of the length of stay/service will be based solely on whether continued Inpatient Care or other health care services are Medically Necessary. If the extension is determined not to be Medically Necessary, the coverage for the length of stay/service will not be extended, except as otherwise described in the Appeal Procedure section of this Contract. A length of stay/service review, also known as a concurrent Medical Necessity review, occurs when the Member, the Member’s provider, or other authorized representative submits a request to The Plan for continued services. If the Member, the Member’s provider or authorized representative requests to extend care beyond the approved time limit and it is a request involving Urgent Care or an ongoing course of treatment, The Plan will make a determination on the request as soon as possible but no later than 48 hours after it receives an urgent request, within 48 hours after it receives requested information (if the initial request is incomplete), or within seven business days after receipt of a non-urgent concurrent request. Recommended Clinical Review A Recommended Clinical Review is a Medical Necessity review for a covered service that occurs before services are completed and helps limit the situations where the Member may have to pay for a non-approved service. The Plan will review a Clinical Review request to determine if it meets approved Blue Cross and Blue Shield of Montana M...
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Failure to Obtain Prior Authorization. If an Insured fails to follow the Plan’s procedures for filing a request for Prior Authorization (Pre-Service Claim), the Insured shall be notified of the failure and the proper procedures to be followed in order to obtain Prior Authorization provided the Insured’s request for Prior Authorization is received by an employee or department of the Plan customarily responsible for handling benefit matters and the original request specifically named the Insured, a specific medical condition or symptom, and a specific treatment, service or product for which approval is requested. The Insured notification of correct Prior Authorization procedures from the Plan shall be provided as soon as possible, but not later than five (5) days (twenty-four (24) hours in the case of an Urgent Care Claim) following the Plan’s receipt of the Insured’s original request. Notification by SHL may be oral unless specifically requested in writing by the Insured. Agreement of Coverage
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Failure to Obtain Prior Authorization.  The specific reason or reasons for upholding the Adverse Benefit Determination;  Reference to the specific Plan provisions on which the determination is based;  A description of any additional material or information necessary for the Claim for Benefits to be approved, modified or reversed, and an explanation of why such material or information is necessary;  A description of the review procedures and the time limits applicable to such procedures;
Sample 1

Related to Failure to Obtain Prior Authorization

  • Prior Authorization A determination to authorize a Provider’s request, pursuant to services covered in the MississippiCAN Program, to provide a service or course of treatment of a specific duration and scope to a Member prior to the initiation or continuation of the service.

  • Network Authorization For services that cannot be provided by a network provider, you can request a network authorization to seek services from a non-network provider. With an approved network authorization, the network benefit level will apply to the authorized covered healthcare service. If we approve a network authorization for you to receive services from a non- network provider, our reimbursement will be based on the lesser of our allowance, the non-network provider’s charge, or the benefit limit. For more information, please see the How Non-Network Providers Are Paid section.

  • Authorization, Etc This Agreement and the Notes have been duly authorized by all necessary corporate action on the part of the Company, and this Agreement constitutes, and upon execution and delivery thereof each Note will constitute, a legal, valid and binding obligation of the Company enforceable against the Company in accordance with its terms, except as such enforceability may be limited by (i) applicable bankruptcy, insolvency, reorganization, moratorium or other similar laws affecting the enforcement of creditors’ rights generally and (ii) general principles of equity (regardless of whether such enforceability is considered in a proceeding in equity or at law).

  • Authorization Required Prior to Parallel Operation 2.2.1 The NYISO, in consultation with the Connecting Transmission Owner, shall use Reasonable Efforts to list applicable parallel Operating Requirements in Attachment 5 of this Agreement. Additionally, the NYISO, in consultation with the Connecting Transmission Owner, shall notify the Interconnection Customer of any changes to these requirements as soon as they are known. The NYISO and Connecting Transmission Owner shall make Reasonable Efforts to cooperate with the Interconnection Customer in meeting requirements necessary for the Interconnection Customer to commence parallel operations by the in-service date.

  • Work Authorization By entering into this Agreement, the Judicial Council only authorizes the Criteria Architect to begin its Work on the Phase indicated on the Coversheet of the Agreement. The Judicial Council has the sole and unilateral right to authorize additional Phases, however, those authorizations will be made in the form of an amendment pursuant to this Agreement, authorizing the appropriate Phase and funding specified herein, which must be executed by the Criteria Architect and the Judicial Council. Work for additional Phases added to the Agreement by amendment will be authorized using Notice to Proceed. Criteria Architect is not authorized to begin any work or services marked “NYA” (Not Yet Authorized).

  • WORK AUTHORIZATIONS The State will issue work authorizations using the form included in Attachment D (Work Authorizations and Supplemental Work Authorizations) to authorize all work under this contract. The Engineer must sign and return a work authorization within seven (7) working days after receipt. Refusal to accept a work authorization may be grounds for termination of the contract. The State shall not be responsible for actions by the Engineer or any costs incurred by the Engineer relating to work not directly associated with or prior to the execution of a work authorization. Terms and conditions governing the use of work authorizations are set forth in Attachment A, General Provisions, Article 1.

  • Authorization Warranty The Contractor represents and warrants that the person executing this Contract for the Contractor is an authorized agent who has actual authority to bind the Contractor to each and every term, condition, and obligation of this Contract and that all requirements of the Contractor have been fulfilled to provide such actual authority.

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