Common use of Notification of Coverage and Authorization Determinations Clause in Contracts

Notification of Coverage and Authorization Determinations. For all authorization determinations, the Contractor must notify the ordering provider, requesting facility, and the Enrollee in writing. The Contractor must follow all timeframes outlined in the Timeframes for Authorization Decisions and Notification of Coverage and Authorization Determinations sections of the IFC contract. The notice shall explain the following: The decision the Contractor has taken or intends to take. The reasons for the decision, in easily understood language including citation to any Contractor guidelines, protocols, or other criteria that were used to make the decision, and how to access the guidelines, protocols or other criteria. A statement of whether the Enrollee has any liability for payment. Information regarding whether and how the Enrollee may Appeal the decision. The Enrollee’s right to receive the Contractor’s assistance in filing an Appeal and how to request it, including access to services for Enrollees with communication barriers or disabilities.

Notification of Coverage and Authorization Determinations. For all authorization determinations, the Contractor must notify the ordering provider, requesting facility, and the Enrollee in writing. The Contractor must follow all timeframes outlined in the Timeframes for Authorization Decisions and Notification of Coverage and Authorization Determinations sections of the IFC IMC contract. The notice shall explain the following: The decision the Contractor has taken or intends to take. The reasons for the decision, in easily understood language including citation to any Contractor guidelines, protocols, or other criteria that were used to make the decision, and how to access the guidelines, protocols or other criteria. A statement of whether the Enrollee has any liability for payment. Information regarding whether and how the Enrollee may Appeal the decision. The Enrollee’s right to receive the Contractor’s assistance in filing an Appeal and how to request it, including access to services for Enrollees with communication barriers or disabilities.