Common use of Prior Approval Decisions Clause in Contracts

Prior Approval Decisions. SAMPLE We will notify you or your representative, and your Provider, of our Prior Approval decisions. Our Prior Approval decisions will discuss whether the requested service is Medically Necessary and is a Covered Service. A denial of coverage based on Medical Necessity (sometimes referred to as an Adverse Health Care Treatment Decision) are initially communicated verbally to the Provider for Exigent Circumstances/Urgent service requests. Written notification is sent to you or your representative and the Provider for Exigent Circumstances/Urgent and routine requests. The written notification cites the reason(s) why the decision was made and includes information about the Appeals process and the right to request in writing copies of any clinical criteria applied in a denial of coverage decision. Additionally, Members will receive written notification of any denial of coverage that is based on non-covered Benefits or Benefit limits that have been reached (known as an Adverse Benefit Determination). The written notification cites the reason(s) why the decision was made and includes information about the Appeals process and the right to request in writing copies of any criteria applied in a denial of coverage decision. Adverse Benefit Determinations also include Claim Denials and are described in section 6.A. For more information on the process for appealing Adverse Health Care Treatment Decisions or Adverse Benefit Determinations, please see section 8, Appeals and Complaints. A request by a provider for Prior Approval of routine medical and behavioral health services and formulary drugs requiring Prior Approval will be reviewed within 72 hours or two (2) business days, whichever is less. If the provider has not submitted all necessary information, Health Options will request additional information within this timeframe. The provider has two (2) business days to submit information. At the end of the two business days or upon receipt of the requested information (whichever is less), a decision will be made within 72 hours or (2) business days (whichever is less) based on submitted information. A request by a provider regarding Exigent Circumstances for concurrent medical services (ongoing care such as an inpatient admission) requests will be reviewed within 24 hours or one (1) calendar day. If the provider has not submitted all necessary information, Health Options will request additional information within this timeframe. The Provider has one (1) business day to submit information. At the end of one (1) business day or upon the receipt of the requested information (whichever is less), a decision will be made within 24 hours or one (1) calendar day based on the submitted information. A request by a provider for Exigent Circumstances regarding medical, behavioral health and prescription drugs on the formulary, will be reviewed within 24 hours or one (1) calendar day. If the provider has not submitted all necessary information, Health Options or the PBM, as applicable, will request additional information within this timeframe. The Provider has 24 hours or one (1) calendar day to submit information. At the end of 24 hours or one calendar day or upon receipt of the requested information (whichever is less), a decision will be made within 24 hours or one (1) calendar day (whichever is less) based on the submitted information. Requests for approval for post-service medical and behavioral health services and prescription services will be reviewed, based on submitted information at the time of request, and a decision will be made within 30 calendar days. Please visit xxxxx://xxx.xxxxxxxxxxxxx.xxx/ for further detailed information on the Prior Approval/authorization process and related requirements.

Prior Approval Decisions. SAMPLE We will notify you or your representative, and your Provider, of our Prior Approval decisions. Our Prior Approval decisions will discuss whether the requested service is Medically Necessary and is a Covered Service. A denial of coverage based on Medical Necessity (sometimes referred to as an Adverse Health Care Treatment Decision) are initially communicated verbally to the Provider for Exigent Circumstances/Urgent service requests. Written notification is sent to you or your representative and the Provider for Exigent Circumstances/Urgent and routine requests. The written notification cites the reason(s) why the decision was made and includes information about the Appeals process and the right to request in writing copies of any clinical criteria applied in a denial of coverage decision. Additionally, Members will receive written notification of any denial of coverage that is based on non-covered administrative policy, non‐covered Benefits or Benefit limits that have been reached (known as an Adverse Benefit Determination). The written notification cites the reason(s) why the decision was made and includes information about the Appeals process and the right to request in writing copies of any criteria applied in a denial of coverage decision. Adverse Benefit Determinations also include Claim Denials and are described in section 6.A. For more information on the process for appealing Adverse Health Care Treatment Decisions or Adverse Benefit Determinations, please see section 8, Appeals and Complaints. A request by a provider for Prior Approval of routine medical and behavioral health services and formulary drugs requiring Prior Approval will be reviewed within 72 hours or two (2) business days, whichever is less. If we do not grant or deny a request for prior authorization within these timeframes the request is granted. If the provider has not submitted all necessary information, Community Health Options will request additional information within this timeframe. The provider has two (2) business days to submit information. At the end of the two business days or upon receipt of the requested information (whichever is less), a decision will be made within 72 hours or (2) business days (whichever is less) based on submitted information. A request by a provider regarding Exigent Circumstances for concurrent medical services (ongoing care such as an inpatient admission) requests will be reviewed within 24 hours or one (1) calendar day. If the provider has not submitted all necessary information, Community Health Options will request additional information within this timeframe. The Provider has one (1) business day to submit information. At the end of one (1) business day or upon the receipt of the requested information (whichever is less), a decision will be made within 24 hours hours, or one (1) calendar day based on the submitted information. A request by a provider for Exigent Circumstances regarding medical, behavioral health and prescription drugs on the formulary, will be reviewed within 24 hours or one (1) calendar day. If the provider has not submitted all necessary information, Community Health Options or the PBM, as applicable, will request additional information within this timeframe. The Provider has 24 hours or one (1) calendar day to submit information. At the end of 24 hours or one calendar day or upon receipt of the requested information (whichever is less), a decision will be made within 24 hours or one (1) calendar day (whichever is less) based on the submitted information. Requests for approval for post-service post‐service medical and behavioral health services and prescription services will be reviewed, based on submitted information at the time of request, and a decision will be made within 30 calendar days. Please visit xxxxx://xxx.xxxxxxxxxxxxx.xxx/ for further detailed information on the Prior Approval/authorization process and related requirements.

Prior Approval Decisions. SAMPLE We will notify you or your representative, and your Provider, of our Prior Approval decisions. Our Prior Approval decisions will discuss whether the requested service is Medically Necessary and is a Covered Service. A denial of coverage based on Medical Necessity (sometimes referred to as an Adverse Health Care Treatment Decision) are initially communicated verbally to the Provider for Exigent Circumstances/Urgent service requests. Written notification is sent to you or your representative and the Provider for Exigent Circumstances/Urgent and routine requests. The written notification cites the reason(s) why the decision was made and includes information about the Appeals process and the right to request in writing copies of any clinical criteria applied in a denial of coverage decision. Additionally, Members will receive written notification of any denial of coverage that is based on non-covered Administrative policy, non‐covered Benefits or Benefit limits that have been reached (known as an Adverse Benefit Determination). The written notification cites the reason(s) why the decision was made and includes information about the Appeals process and the right to request in writing copies of any criteria applied in a denial of coverage decision. Adverse Benefit Determinations also include Claim Denials and are described in section 6.A. For more information on the process for appealing Adverse Health Care Treatment Decisions or Adverse Benefit Determinations, please see section 8, Appeals and Complaints. A request by a provider for Prior Approval of routine medical and behavioral health services and formulary drugs requiring Prior Approval will be reviewed within 72 hours or two (2) business days, whichever is less. If we do not grant or deny a request for prior authorization within these timeframes the request is granted. If the provider has not submitted all necessary information, Community Health Options will request additional information within this timeframe. The provider has two (2) business days to submit information. At the end of the two business days or upon receipt of the requested information (whichever is less), a decision will be made within 72 hours or (2) business days (whichever is less) based on submitted information. A request by a provider regarding Exigent Circumstances for concurrent medical services (ongoing care such as an inpatient admission) requests will be reviewed within 24 hours or one (1) calendar day. If the provider has not submitted all necessary information, Community Health Options will request additional information within this timeframe. The Provider has one (1) business day to submit information. At the end of one (1) business day or upon the receipt of the requested information (whichever is less), a decision will be made within 24 hours hours, or one (1) calendar day based on the submitted information. A request by a provider for Exigent Circumstances regarding medical, behavioral health and prescription drugs on the formulary, will be reviewed within 24 hours or one (1) calendar day. If the provider has not submitted all necessary information, Community Health Options or the PBM, as applicable, will request additional information within this timeframe. The Provider has 24 hours or one (1) calendar day to submit information. At the end of 24 hours or one calendar day or upon receipt of the requested information (whichever is less), a decision will be made within 24 hours or one (1) calendar day (whichever is less) based on the submitted information. Requests for approval for post-service post‐service medical and behavioral health services and prescription services will be reviewed, based on submitted information at the time of request, and a decision will be made within 30 calendar days. Please visit xxxxx://xxx.xxxxxxxxxxxxx.xxx/ for further detailed information on the Prior Approval/authorization process and related requirements.

Prior Approval Decisions. SAMPLE We will notify you or your representative, and your Provider, of our Prior Approval decisions. Our Prior Approval decisions decisio ns will discuss whether the requested service is Medically Necessary and is a Covered Service. A denial of coverage based on Medical Necessity (sometimes referred to as an Adverse Health Care Treatment Decision) are initially communicated verbally to the Provider for Exigent Circumstances/Circumstances/ Urgent service requests. Written notification is sent to you or your representative and the Provider for Exigent Circumstances/Urgent Circumstances/ U rgent and routine requestsrequests . The written notification cites the reason(s) why the decision was w as made and includes information about the Appeals process and the right to request in writing copies of any clinical criteria applied in a denial of coverage decision. Additionally, Members will receive written notification of any denial of coverage that is based on non-non - covered Benefits or Benefit limits that have been reached (known as an Adverse Benefit Determination). The written notification cites the reason(s) why the decision was made and includes information about the Appeals process and the right to request in writing copies of any criteria applied in a denial of coverage decision. Adverse Benefit Determinations also include Claim Denials and are described in section 6.A. For more information on the process for appealing Adverse Health Care Treatment Trea tment Decisions or Adverse Benefit Determinations, please see section 8, Appeals and Complaints. A request by a provider for Prior Approval of routine medical and behavioral health services and formulary drugs requiring Prior Approval will be reviewed within with in 72 hours or two (2) business days, whichever is less. If the provider has not submitted all necessary information, Health Options will request additional information within this timeframe. The provider has two (2) business days to submit information. At the end of the two business days or upon receipt of the requested information (whichever is less), a decision will be made within 72 hours or (2) business days (whichever is less) based on submitted information. A request by a provider regarding Exigent Exige nt Circumstances for concurrent medical services (ongoing care such as an inpatient admission) requests will be reviewed within 24 hours or one (1) calendar day. If the provider has not submitted all necessary information, Health Options will request additional addit ional information within this timeframe. The Provider has one (1) business day to submit information. At the end of one (1) business day or upon the receipt of the requested information (whichever is less), a decision will be made within 24 hours or one (1) calendar day based on the submitted information. A request by a provider for Exigent Circumstances regarding medical, behavioral health and prescription drugs on the formulary, will be reviewed within 24 hours or one (1) calendar day. If the provider has not submitted all necessary information, Health Options Op tions or the PBM, as applicable, will request additional information within this timeframe. The Provider has 24 hours or one (1) calendar day to submit information. At the end of 24 hours or one calendar day or upon receipt of the requested information (whichever is less), a decision will be made within 24 hours or one (1) calendar day (whichever is less) based on the submitted information. Requests for approval for post-post - service medical and behavioral health services and prescription services will be reviewedrevi ewed, based on submitted information at the time of request, and a decision will be made within 30 calendar days. Please visit xxxxx://xxx.xxxxxxxxxxxxx.xxx/ https:// xxx.xxxxxxxxxxxxx.xxx/ for further detailed information on the Prior Approval/Approval/ authorization process and related requirementsrequire ments.

Prior Approval Decisions. SAMPLE We will notify you or your representative, and your Provider, of our Prior Approval decisions. Our Prior Approval decisions will discuss whether the requested service is Medically Necessary and is a Covered Service. A denial of coverage based on Medical Necessity (sometimes referred to as an Adverse Health Care Treatment Decision) are initially communicated verbally to the Provider for Exigent Circumstances/Urgent service requests. Written notification is sent to you or your representative and the Provider for Exigent Circumstances/Urgent and routine requests. The written notification cites the reason(s) why the decision was made and includes information about the Appeals process and the right to request in writing copies of any clinical criteria applied in a denial of coverage decision. Additionally, Members will receive written notification of any denial of coverage that is based on non-covered Benefits or Benefit limits that have been reached (known as an Adverse Benefit Determination). The written notification cites the reason(s) why the decision was made and includes information about the Appeals process and the right to request in writing copies of any criteria applied in a denial of coverage decision. Adverse Benefit Determinations also include Claim Denials and are described in section 6.A. For more information on the process for appealing Adverse Health Care Treatment Decisions or Adverse Benefit Determinations, please see section 8, Appeals and Complaints. SAMPLE A request by a provider for Prior Approval of routine medical and behavioral health services and formulary drugs requiring Prior Approval will be reviewed within 72 hours or two (2) business days, whichever is less. If the provider has not submitted all necessary information, Health Options will request additional information within this timeframe. The provider has two (2) business days to submit information. At the end of the two business days or upon receipt of the requested information (whichever is less), a decision will be made within 72 hours or (2) business days (whichever is less) based on submitted information. A request by a provider regarding Exigent Circumstances for concurrent medical services (ongoing care such as an inpatient admission) requests will be reviewed within 24 hours or one (1) calendar day. If the provider has not submitted all necessary information, Health Options will request additional information within this timeframe. The Provider has one (1) business day to submit information. At the end of one (1) business day or upon the receipt of the requested information (whichever is less), a decision will be made within 24 hours or one (1) calendar day based on the submitted information. A request by a provider for Exigent Circumstances regarding medical, behavioral health and prescription drugs on the formulary, will be reviewed within 24 hours or one (1) calendar day. If the provider has not submitted all necessary information, Health Options or the PBM, as applicable, will request additional information within this timeframe. The Provider has 24 hours or one (1) calendar day to submit information. At the end of 24 hours or one calendar day or upon receipt of the requested information (whichever is less), a decision will be made within 24 hours or one (1) calendar day (whichever is less) based on the submitted information. Requests for approval for post-service medical and behavioral health services and prescription services will be reviewed, based on submitted information at the time of request, and a decision will be made within 30 calendar days. Please visit xxxxx://xxx.xxxxxxxxxxxxx.xxx/ for further detailed information on the Prior Approval/authorization process and related requirements.