Preauthorization. Services for which preauthorization is recommended are marked with an asterisk (*) in the Summary of Medical Benefits. Preauthorization is defined in Section 8.0. BCBSRI network providers are responsible for obtaining preauthorization for all applicable covered health care services. BlueCard providers are responsible for obtaining preauthorization for all applicable inpatient facility covered health care services. In some circumstances, you are responsible for obtaining preauthorization. In order for you to obtain preauthorization for a covered health care service, please do the following: For all covered health care services (except mental health and substance abuse), provided by non-network providers or for non-inpatient facility services provided by another Blue Cross plan’s designated BlueCard provider call our Customer Service Department. For mental health and substance abuse services provided by non-network providers or for non-inpatient facility services provided by another Blue Cross plan’s designated BlueCard provider call 0-000-000-0000 prior to receiving care. Lines are open 24 hours a day, 7 days per week. If you are responsible for obtaining preauthorization, we will send to you notification of the preauthorization determination within fourteen (14) calendar days from receipt of the request or prior to the date of service. Please see Section 8.0 for the definition of preauthorization. You may request an expedited preauthorization review if the circumstances are an emergency. If an expedited preauthorization review is received by us, we will respond to you with a determination within seventy-two (72) hours or in less than seventy two (72) hours (taking into consideration medical exigencies)following receipt of the request. Services for which prescription drug preauthorization is required are marked with the symbol (+) in the Summary of Pharmacy Benefits. To obtain the required prescription drug preauthorization for certain covered prescription drugs please request your prescribing physician to call our pharmacy benefits administrator, using the number listed for the “Pharmacist” on the back of your ID card. You can call our Customer Service Department at (000) 000-0000 or 0-000-000-0000 or visit our Web site at XXXXXX.xxx to see if a prescription drug requires prescription drug preauthorization. Prescription drug preauthorization is defined in Section 3.27.
Preauthorization. The Health Services listed below do not require Preauthorization.
(A) Emergency Services.
(B) Preventive Services provided by a Participating Provider. A Provider that provides [You][an Enrollee] with Emergency Services may not charge You except for an applicable Copay or Deductible. All other Health Services must be made through Your PMP. [Your][An Enrollee’s] PMP will determine whether Preauthorization is required. The following is a list of Health Services that require Preauthorization. This list is not exhaustive.
(A) Elective/Urgent Inpatient Admissions.
Preauthorization. Preauthorization, the pretreatment review by Blue Shield or Health Plan of a treatment plan and/or treatment site, is a contractual obligation under the terms of the Administrative Requirements and certain Member Plan Documents. Preauthorization must be requested prior to the initiation of certain services in accordance with the Member’s Plan Documents. Blue Shield or Health Plan may require certain clinical records and diagnostic aids relating to a Member to be included with requests for preauthorization. Charges for services rejected because Provider failed to initiate or receive preauthorization shall not be collected from the Member.
Preauthorization. Preauthorization, the pretreatment review by Highmark or Health Plan of a treatment plan, service, and/or treatment site, is a contractual obligation under the terms of the Member Plan Documents. Preauthorization must be requested prior to the initiation of certain services in accordance with the Member’s Plan Document. Highmark or Health Plan may require certain clinical records and diagnostic aids relating to a Member to be included with requests for preauthorization and Professional Provider agrees to provide such information in a timely manner. Charges for services denied because Professional Provider failed to initiate or receive preauthorization may not be collected from the Member. Appeal processes applicable to the Member may be Professional Provider’s only recourse.
Preauthorization. A dentist may submit to HDS a request for preauthorization of services. If the preauthorization is approved, HDS will provide to the dentist an estimate of the HDS Share and the Patient Share. An HDS preauthorization reserves the HDS Share against the Member’s Plan Maximum for up to one year from the date of the preauthorization. Actual amounts payable as HDS Share are subject to the HDS Plan, Coverage Limitations, fee schedules, and eligibility status on the date that the service is actually performed.
D. Appeals Process
1. If HDS denies payment of a service in whole or in part, a Member may request a copy of the specific rule, guideline, or protocol relied upon by HDS in making the adverse benefit determination which will be provided free of charge upon request by Member to HDS. Any denial of payment by HDS will identify the claim involved and the reason for non-payment.
Preauthorization. Preauthorization by VA is not required for Eligible AI/AN Veterans receiving direct care or THP pre-authorized Purchased Referred Care (PRC). Preauthorization is required for medications not on VA’s formulary.
Preauthorization. Employer shall furnish Hospital with a timely and reliable system for identifying Employees. Hospital shall use reasonable efforts to confirm Employee’s status with Employer. Employer shall have no duty to cover the costs of services for anyone who is not an Employee or Dependant except as set forth in 3.a.
Preauthorization. The sole responsibility for obtaining any necessary preauthorization rests with Provider or the participating provider who recommends or orders said services, treatments, or procedures, not with the Members.
Preauthorization. If the participant’s physician is recommending medical treatment on a referral basis outside of Canada that is expected to cost more than $1,000, the participant should request pre-authorization to ensure that the expenses are covered.
Preauthorization. Once a Blue Plan65 Select Member exhausts his/her benefits under Medicare, Hospital agrees to obtain Preauthorization for such Member as outlined in Article VI of the Agreement and Article V of this Blue Plan65 Select Addendum.
