Common use of Member FFS Authorizations Clause in Contracts

Member FFS Authorizations. The MCP must honor any current FFS prior authorization to allow its new members that are transitioning from FFS to receive services from the authorized provider, regardless of whether the authorized provider is a panel or out-of-panel provider, for the following approved services: i. An organ, bone marrow, or hematopoietic stem cell transplant pursuant to OAC rule 5160-2-07.1 and 2.b.vii of Appendix G; ii. Dental services that have not yet been received; iii. Vision services that have not yet been received; iv. Durable medical equipment (DME) that has not yet been received. Ongoing DME services and supplies are to be covered by the MCP as previously authorized until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5160-26-03.1. v. Private Duty Nursing (PDN) services. Except for ABD members under 21 years of age and those under 21 with an SSI indicator, PDN services must be covered at the previously-authorized service level until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5160-26-03. 1. As soon as the MCP becomes aware of the member’s current FFS authorization approval, the MCP must initiate contact with the authorized provider and member as applicable to ensure continuity of care. The MCP must implement a plan to meet the member’s immediate and ongoing medical needs and coordinate the transfer of services to a panel provider, if appropriate. For organ, bone marrow or hematopoietic stem cell transplants, MCPs must receive prior approval from ODM to transfer services to a panel provider. When an MCP medical necessity review results in a decision to reduce, suspend, or terminate services previously authorized by FFS Medicaid, the MCP must notify the member of his or her state hearing rights no less than 15 calendar days prior to the effective date of the MCP’s proposed action, per OAC rule 5160-26-08.4.

Member FFS Authorizations. The MCP must honor any current FFS prior authorization to allow its new members that are transitioning from FFS to receive services from the authorized provider, regardless of whether the authorized provider is a panel or out-of-panel provider, for the following approved services: i. An organ, bone marrow, or hematopoietic hematapoietic stem cell transplant pursuant to OAC rule 5160-2-07.1 and 2.b.vii of Appendix G; ii. Dental services that have not yet been received; iii. Vision services that have not yet been received; iv. Durable medical equipment (DME) that has not yet been received. Ongoing DME services and supplies are to be covered by the MCP as previously authorized until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5160-26-03.1. v. Private Duty Nursing (PDN) services. Except for ABD members under 21 years of age and those under 21 with an SSI indicator, PDN services must be covered at the previously-authorized service level until the MCP conducts a medical necessity review and renders an authorization decision pursuant to OAC rule 5160-26-03. 1. As soon as the MCP becomes aware of the member’s current FFS authorization approval, the MCP must initiate contact with the authorized provider and member as applicable to ensure continuity of care. The MCP must implement a plan to meet the member’s immediate and ongoing medical needs and coordinate the transfer of services to a panel provider, if appropriate. For organ, bone marrow or hematopoietic hematapoietic stem cell transplants, MCPs must receive prior approval from ODM to transfer services to a panel provider. When an MCP medical necessity review results in a decision to reduce, suspend, or terminate services previously authorized by FFS Medicaid, the MCP must notify the member of his or her state hearing rights no less than 15 calendar days prior to the effective date of the MCP’s proposed action, per OAC rule 5160-26-08.4.