Common use of Prior Auth Required Clause in Contracts

Prior Auth Required. Practitioner/Provider agrees to accept our normal reimbursement for similar services and services are provided in New Mexico.  Any care related to the Cancer Clinical Trial that is Investigational requires Prior Authorization. Other medical services that are not Investigational may require Prior Authorization as described in the Prior Authorization Section. Excl sion  Cer ified Hospice Care This benefit has one or more exclusions as specified in the Exclusions section. u Benefits for Inp tient and in-home Hospice services are Covered if you are terminally ill. Prior Auth Required Services must be provided by an approved Hospice program during a Hospice benefit period and will not be Covered to the extent that they duplicate other Covered Services available to you. Benefits that are provided for by a Hospice or other facility require approval by your Practitioner/Provider and our Prior Authorization. The Hospice benefit period is defined as follows:  Beginning on the date your Practitioner/Provider certifies that you are terminally ill with a life expectancy of six months or less.  Ending six months after it began, u period below, or upon your death. less you require an extension of the Hospice benefit  If you require an extension of the Hospice benefit period, the Hospice must provide a new treatment plan and your Practitioner/Provider must re-authorize your medical condition to us. We will not Authorize more than one additional Hospice benefit period.  You must be a Covered Member throughout your Hospice benefit period. The following services are Covered:  Inpatient Hospice care  Practitioner/Provider visits by Certified Hospice Practitioner/Providers  Home Health Care Services by approved home health care personnel  Physical therapy  Medical supplies  Prescription Drugs and Medication for the pain and discomfort specifically related to the terminal illness  Medical transportation  Respite care (care that provides a relief for the care-giver) for a period not to exceed five continuous days for every 60 days of Hospice care. No more than two respite care stays will be available during a Hospice benefit period.

Prior Auth Required. Practitioner/Provider agrees to accept our normal reimbursement for similar services and services are provided in New Mexico.  • Any care related to the Cancer Clinical Trial that is Investigational requires Prior Authorization. Other medical services that are not Investigational may require Prior Authorization as described in the Prior Authorization Section. Excl sion  ⮚ Cer ified Hospice Care This benefit has one or more exclusions as specified in the Exclusions section. u Benefits for Inp tient and in-home Hospice services are Covered if you are terminally ill. Prior Auth Required Services must be provided by an approved Hospice program during a Hospice benefit period and will not be Covered to the extent that they duplicate other Covered Services available to you. Benefits that are provided for by a Hospice or other facility require approval by your Practitioner/Provider and our Prior Authorization. The Hospice benefit period is defined as follows:  • Beginning on the date your Practitioner/Provider certifies that you are terminally ill with a life expectancy of six months or less.  • Ending six months after it began, u period below, or upon your death. less you require an extension of the Hospice benefit  • If you require an extension of the Hospice benefit period, the Hospice must provide a new treatment plan and your Practitioner/Provider must re-authorize your medical condition to us. We will not Authorize more than one additional Hospice benefit period.  • You must be a Covered Member throughout your Hospice benefit period. The following services are Covered:  • Inpatient Hospice care  • Practitioner/Provider visits by Certified Hospice Practitioner/Providers  • Home Health Care Services by approved home health care personnel  • Physical therapy  • Medical supplies  • Prescription Drugs and Medication for the pain and discomfort specifically related to the terminal illness  • Medical transportation  • Respite care (care that provides a relief for the care-giver) for a period not to exceed five continuous days for every 60 days of Hospice care. No more than two respite care stays will be available during a Hospice benefit period.

Prior Auth Required. Exclusion • If services are not available from an In-network Practitioner/Provider, we will cover services of an Out-of-network Practitioner/Provider only if the Out-of- network Practitioner/Provider agrees to accept our normal reimbursement for similar services and services are provided in New Mexico.  • Any care related to the Cancer Clinical Trial that is Investigational requires may require Prior Authorization. Other medical services that are not Investigational may require Prior Authorization as described in the Prior Authorization Section. Excl sion  Cer ified Certified Hospice Care This benefit has one or more exclusions as specified in the Exclusions section. u Benefits for Inp tient Inpatient and in-home Hospice services are Covered if you are terminally ill. Prior Auth Required Services must be provided by an approved Hospice program during a Hospice benefit period and will not be Covered to the extent that they duplicate other Covered Services available to you. Benefits that are provided for by a Hospice or other facility require approval by your Practitioner/Provider and our Prior Authorization. • The Hospice benefit period is defined as follows:  o Beginning on the date your Practitioner/Provider certifies that you are terminally ill with a life expectancy of six months or less.  o Ending six months after it began, u unless you require an extension of the Hospice benefit period below, or upon your death. less you require an extension of the Hospice benefit  o If you require an extension of the Hospice benefit period, the Hospice must provide a new treatment plan and your Practitioner/Provider must re-authorize your medical condition to us. We will not Authorize more than one additional Hospice benefit period.  o You must be a Covered Member throughout your Hospice benefit period. • The following services are Covered:  o Inpatient Hospice care  o Practitioner/Provider visits by Certified Hospice Practitioner/Providers  o Home Health Care Services by approved home health care personnel  o Physical therapy  o Medical supplies  o Prescription Drugs and Medication for the pain and discomfort specifically related to the terminal illness  o Medical transportation  o Respite care (care that provides a relief for the care-giver) for a period not to exceed five continuous days for every 60 days of Hospice care. No more than two respite care stays will be available during a Hospice benefit period.

Prior Auth Required. Practitioner/Provider agrees to accept our normal reimbursement for similar services and services are provided in New Mexico.  Any care related to the Cancer Clinical Trial that is Investigational requires may require Prior Authorization. Other medical services that are not Investigational may require Prior Authorization as described in the Prior Authorization Section. Excl sion  Cer ified Certified Hospice Care This benefit has one or more exclusions as specified in the Exclusions section. u Benefits for Inp tient Inpatient and in-home Hospice services are Covered if you are terminally ill. Prior Auth Required Services must be provided by an approved Hospice program during a Hospice benefit period and will not be Covered to the extent that they duplicate other Covered Services available to you. Benefits that are provided for by a Hospice or other facility require approval by your Practitioner/Provider and our Prior Authorization.  The Hospice benefit period is defined as follows:  o Beginning on the date your Practitioner/Provider certifies that you are terminally ill with a life expectancy of six months or less.  o Ending six months after it began, u unless you require an extension of the Hospice benefit period below, or upon your death. less you require an extension of the Hospice benefit  o If you require an extension of the Hospice benefit period, the Hospice must provide a new treatment plan and your Practitioner/Provider must re-authorize your medical condition to us. We will not Authorize more than one additional Hospice benefit period.  o You must be a Covered Member throughout your Hospice benefit period.  The following services are Covered:  o Inpatient Hospice care  o Practitioner/Provider visits by Certified Hospice Practitioner/Providers  o Home Health Care Services by approved home health care personnel  o Physical therapy  o Medical supplies  o Prescription Drugs and Medication for the pain and discomfort specifically related to the terminal illness  o Medical transportation  o Respite care (care that provides a relief for the care-giver) for a period not to exceed five continuous days for every 60 days of Hospice care. No more than two respite care stays will be available during a Hospice benefit period.

Prior Auth Required. Inpatient means you have been admitted by a health care Practitioner/Provider agrees to accept our normal reimbursement a Hospital for similar services and the purposes of receiving Hospital services. Eligible Inpatient Hospital services are acute care services provided when you are a registered bed patient and there is a room and board charge. Admissions are considered Inpatient based on Medical Necessity, regardless of the length of time spent in New Mexicothe Hospital.  Any care related to the Cancer Clinical Trial that is Investigational requires Hospital admissions (Inpatient, non-emergent) require Prior Authorization. Other medical Inpatient services that provided by Out-of-network Practitioners/Providers or facilities are not Investigational may require Covered except as provided in How This Plan Works, Accidental Injury / Urgent Care efer to /Emergency Health Services / Observation / Trauma Services, and Eligibility, R Enrollment and Termination and Continuation Sections of this Agreement. Inpatient Hospital benefits also includes Acute medical detoxification.  Hyperbaric Oxygen Therapy Prior Auth Required Hyperbaric Oxygen Therapy is a covered benefit only if the therapy is proposed for a condition recognized as one of the accepted indications as defined by the Hyperbaric Oxygen Therapy Committee of The Undersea and Hyperbaric Medical Society (UHMS). Hyperbaric Oxygen Therapy is Excluded for any other condition. Hyperbaric Oxygen Therapy requires Prior Authorization as described and services must be provided by your In-network Practitioner/Provider in the Prior Authorization Sectionorder to be Covered. Excl sion  Cer ified Hospice Care Infertility Treatment Infertility Treatment Diagnosis and causing infertility. medically indicated treatments for physical conditions  Mental Health Services and Alcoholism and Substance Abuse Services Exclusion This benefit has one or more exclusions as specified in the Exclusions section. u Benefits  Mental Health Services Some mental health services require Prior Authorization. The In-network Behavioral Health Practitioners/Providers will be responsible for Inp tient obtaining Prior Authorization, when required. For Out-of-network Services, Members need to contact our Behavioral Health Refer to Department to obtain Prior Authorization, when required. Please refer to the Prior Authorization Section for services that require Prior Authorization. For assistance or for questions related to mental health services, you may call our Behavioral Health Department directly at (000) 000-0000 or toll-free at 0-000-000-0000. o Partial Hospitalization can be substituted for the Inpatient mental health services when our Behavioral Health Department approves the Prior Authorization request. Partial Hospitalization is a non-residential, Hospital-based day program that includes various daily and in-home Hospice services are Covered if you are terminally illweekly therapies. Prior Auth Required o Acute medical detoxification benefits are Covered under Inpatient and Outpatient Medical services Authorization. found in the Benefits Section. All services require Prior  Alcohol and Substance Abuse Services must be provided by an approved Hospice program during a Hospice benefit period and will not be Covered to the extent that they duplicate other Covered Services available to youo To obtain Alcoholism/Substance Abuse services, Members may contact our Behavioral Health Department at 505) 923-5470 or toll-free at 0-000-000-0000. Benefits that are provided for by a Hospice or other facility require approval by your The Prior Auth Required Behavioral Health Practitioner/Provider and will be responsible for any additional Prior Authorizations. o For Out-of-network Services, Members need to contact our Behavioral Health Department in order to obtain Prior Authorization. The Hospice benefit period is defined as follows:  Beginning on the date your Practitioner/Provider certifies that you are terminally ill with a life expectancy of six months or less.  Ending six months after it began, u period below, or upon your death. less you require an extension of the Hospice benefit  If you require an extension of the Hospice benefit period, the Hospice must provide a new treatment plan and your Practitioner/Provider must re-authorize your medical condition to us. We will not Authorize more than one additional Hospice benefit period.  You must be a Covered Member throughout your Hospice benefit period. The following services are Covered:  Inpatient Hospice care  Practitioner/Provider visits by Certified Hospice Practitioner/Providers  Home Health Care Services by approved home health care personnel  Physical therapy  Medical supplies  Prescription Drugs and Medication for the pain and discomfort specifically related to the terminal illness  Medical transportation  Respite care (care that provides a relief for the care-giver) for a period not to exceed five continuous days for every 60 days of Hospice care. No more than two respite care stays will be available during a Hospice benefit periodwhen required.