Common use of Managed Care Process Clause in Contracts

Managed Care Process. The Medical Director and/or HPN's Utilization Review Committee will review proposed services and supplies to be received by a Member to determine:  If the services are Medically Necessary and/or appropriate.  The appropriateness of the proposed setting.  The required duration of treatment or admission. Following review, HPN will complete the Prior Authorization written notification and send a copy to the Provider and the Member. The form will specify approved services and supplies. Prior Authorization is not a guarantee of payment. The final decision as to whether any care should be received is between the Member and the Provider. If HPN denies a request by a Member and/or Provider for Prior Authorization of a service or supply, the Member or Provider may appeal the denial to the Grievance Review Committee (see Appeals Procedures Section).

Managed Care Process. The Medical Director and/or HPN's Utilization Review Committee will review proposed services and supplies to be received by a Member to determine:  • If the services are Medically Necessary and/or appropriate.  • The appropriateness of the proposed setting.  • The required duration of treatment or admission. Following review, HPN will complete the Prior Authorization written notification form and send a copy to the Provider and the Member. The Prior Authorization form will specify approved services Covered Services and supplies. Prior Authorization is not a guarantee of paymentpayment for Covered Services. The final decision as to whether any care should be received is between the Member and the Provider. If HPN denies a request by a Member and/or Provider for Prior Authorization of a service or supply, the Member or Provider may appeal the denial to the Grievance Review Committee (see the Appeals Procedures SectionSection herein).

Managed Care Process. The Medical Director and/or HPN's Utilization Review Committee will review proposed services and supplies to be received by a Member to determine:  • If the services are Medically Necessary and/or appropriate.  • The appropriateness of the proposed setting.  • The required duration of treatment or admission. Following review, HPN will complete the Prior Authorization written notification form and send a copy to the Provider and the Member. The form will specify approved services and supplies. Prior Authorization is not a guarantee of payment. The final decision as to whether any care should be received is between the Member and the Provider. If HPN denies a request by a Member and/or Provider for Prior Authorization of a service or supply, the Member or Provider may appeal the denial to the Grievance Review Committee (see Section 11, Appeals Procedures SectionProcedures).

Managed Care Process. The Medical Director and/or HPN's Utilization Review Committee will review proposed services and supplies to be received by a Member to determine:  If the services are Medically Necessary and/or appropriate.  The appropriateness of the proposed setting.  The required duration of treatment or admission. Following review, HPN will complete the Prior Authorization written notification form and send a copy to the Provider and the Member. The form will specify approved services and supplies. Prior Authorization is not a guarantee of payment. The final decision as to whether any care should be received is between the Member and the Provider. If HPN denies a request by a Member and/or Provider for Prior Authorization of a service or supply, the Member or Provider may appeal the denial to the Grievance Review Committee (see Appeals Procedures Section).