Common use of Failure to Obtain Prior Authorization Clause in Contracts

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 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 Medical Policy and/or level of care review criteria for medical and behavioral health services. Once a decision has been made on the services reviewed as part of the Recommended Clinical Review process, the services will not be reviewed for Medical Necessity again on a retrospective basis. Submitted services (subject to Medical Necessity review) not included as part of Recommended Clinical Review may be reviewed retrospectively. To determine if a Recommended Clinical Review is available for a specific service, visit the Blue Cross and Blue Shield of Montana website at xxx.xxxxxx.xxx/xxxx-xxxx/xxxxx-xxx-xx-xxxxxxx/xxxxxxxxxxx-xxxxxxxxxx.xxx for the required Prior Authorization and Recommended Clinical Review list, which is updated when new services are added or when services are removed, or call Customer Service at the number on the back of the Member’s identification card. The Member or provider may request a Recommended Clinical Review. 1. No Guarantee of Payment

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 Review 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 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 Medical Policy and/or level of care review criteria for medical and behavioral health services. Once a decision has been made on the services reviewed as part of the Recommended Clinical Review process, the services will not be reviewed for Medical Necessity again on a retrospective basis. Submitted services (subject to Medical Necessity review) not included as part of Recommended Clinical Review may be reviewed retrospectively. To determine if a Recommended Clinical Review is available for a specific service, visit the Blue Cross and Blue Shield of Montana website at xxx.xxxxxx.xxx/xxxx-xxxx/xxxxx-xxx-xx-xxxxxxx/xxxxxxxxxxx-xxxxxxxxxx.xxx for the required Prior Authorization and Recommended Clinical Review list, which is updated when new services are added or when services are removed, or call Customer Service at the number on the back of the Member’s identification card. The Member or provider may request a Recommended Clinical Review. 1. No Guarantee of Payment