Common use of In Lieu of Services Clause in Contracts

In Lieu of Services. The Contractor may offer cost effective alternative services/equipment to members, where the services/equipment are not identified as an in-plan benefit, when EOHHS has determined that the use of such alternative services/equipment are medically appropriate and cost effective. The Contractor may not require the member to accept an in lieu of service in the place of a covered service. The Contractor has flexibility and may provide all the in lieu of services identified in ATTACHMENT A. If the Contractor seeks to provide an in lieu of service that is not listed in ATTACHMENT A, the Contractor must receive prior authorization from EOHHS to deliver the proposed service as defined in EOHHS MCO Core Contract Requirements for Requesting In Lieu of Services. The Contractor must follow the procedures below for obtaining prior approval for in lieu of services not identified in ATTACHMENT A. • Requests for prior authorization must be submitted by the Contractor only; • Requests for prior authorization must be submitted through completion of the “Request for Cost-Effective Alternative (CEA)” form along with any accompanying documentation; • Submission must be sent by secure email to the designated EOHHS employee; and • To ensure EOHHS has the opportunity to adequately consider all requests for in lieu of services, the Contractor should submit the request at least 30 days prior to the desired date of service. In addition to the services identified in ATTACHMENT A as in lieu of services, another example of an approved in lieu of service is: • Psychiatric or substance use disorder treatment services provided in an Institution for Mental Disease (IMD) for members between the ages of 21-64, subject to the limitations described in 42 C.F.R. § 438.6(e).