Common use of Policies and Procedures for Service Authorization Requests Clause in Contracts

Policies and Procedures for Service Authorization Requests. (A) If requiring Service Authorizations, the Contractor shall establish and follow written policies and procedures for processing requests for initial and continuing authorization of Covered Services. (B) The Contractor shall implement mechanisms to ensure consistent application of review criteria for Service Authorization decisions and consult with the requesting Provider when appropriate. (C) The Contractor shall ensure that any decision to deny a Service Authorization Request or to authorize a service in an amount, duration, or scope that is less than requested, be made by a health care professional who has appropriate clinical expertise in treating the Enrollee’s condition or disease. (D) The Contractor shall notify the requesting Provider, and give the Enrollee written notice of any decision to deny a Service Authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the Provider need not be in writing. (E) The Contractor shall ensure compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue, Medically Necessary services to any Enrollee.

Policies and Procedures for Service Authorization Requests. (A) If requiring Service Authorizations, the Contractor shall establish and follow written policies and procedures for processing requests for initial and continuing authorization of Covered Services. (B) The Contractor shall implement mechanisms to ensure consistent application of review criteria for Service Authorization decisions and consult with the requesting Provider when appropriate. (C) The Contractor shall ensure require that any decision to deny a Service Authorization Request or to authorize a service in an amount, duration, or scope that is less than requested, be made by a health care professional an individual who has appropriate clinical expertise in treating addressing the Enrollee’s condition or diseasebehavioral health needs. (D) The Contractor shall notify the requesting Provider, and give the Enrollee written notice of any decision to deny a Service Authorization requestRequest, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the Provider need not be in writing. (E) The Contractor shall ensure not structure compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue, Medically Necessary services Covered Services to any Enrollee.

Policies and Procedures for Service Authorization Requests. (A) If requiring Service Authorizationsservice authorizations, the Contractor shall establish and follow written policies and procedures for processing requests for initial and continuing authorization of Covered Services. (B) The Contractor shall implement mechanisms to ensure consistent application of review criteria for Service Authorization service authorization decisions and consult with the requesting Provider when appropriate. (C) The Contractor shall ensure require that any decision to deny a Service Authorization Request or to authorize a service in an amount, duration, or scope that is less than requested, be made by a health care professional an individual who has appropriate clinical expertise in treating addressing the Enrollee’s condition medical, behavioral health, or diseaselong-term services and supports needs. (D) The Contractor shall notify the requesting Provider, and give the Enrollee written notice of any decision to deny a Service Authorization requestRequest, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the Provider need not be in writing. (E) The Contractor shall ensure not structure compensation to individuals or entities that conduct utilization management activities is not structured so as to provide incentives for the individual or entity to deny, limit, or discontinue, Medically Necessary services discontinue Covered Services to any Enrollee.