Common use of Prior Auth Required Clause in Contracts

Prior Auth Required. o 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. The Behavioral Practitioner/Provider will be responsible for any additional o For Out-of-network Services, Members need to contact our Behavioral Health Department in order to obtain Prior Authorization, when required. Please refer to the o In all cases, treatmen must be Medically Necessary in order to be Covered. o Acute Medical Detoxification Benefits are Covered under Inpatient and Outpatient Hospital Services found in the Benefits Section of this Agreement. Inpatient Hospital Services must be Prior Authorized.   Nutritional Supplements for prenatal care when prescribed by a Practitioner/Provider are Covered for regnant women.  Nutritional supplements that require a prescription to be dispensed are Covered when prescribed by an In-network Practitioner/Provider and when Medically Necessary to replace a specific documented deficiency. Prior Authorization is required.  Nutritional supplements administered by injection at the Practitioner’s/Provider’s office are Covered when Medically Necessary.  Enteral formulas or products, as Nutritional support, are Covered only when prescribed by an In-network Practitioner/Provider and administered by enteral tube feedings.  Total Parenteral Nutrition (TPN) is the administration of nutrients through intravenous catheters via central or peripheral veins and is Covered when ordered by an In-network Practitioner/Provider.  Special Medical Foods as listed as Covered benefits in the Genetic Inborn Errors of  Outpatient Medical Services

Prior Auth Required. o 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. The Behavioral Practitioner/Provider will be responsible for any additional o For Out-of-network Services, Members need to contact our Behavioral Health Department in order to obtain Prior Authorization, when required. Please refer to the o In all cases, treatmen must be Medically Necessary in order to be Covered. o Acute Medical Detoxification Benefits are Covered under Inpatient and Outpatient Hospital Services found in the Benefits Section of this Agreement. Inpatient Hospital Services must be Prior Authorized.   ⮚ • Nutritional Supplements for prenatal care when prescribed by a Practitioner/Provider are Covered for regnant women.  • Nutritional supplements that require a prescription to be dispensed are Covered when prescribed by an In-network Practitioner/Provider and when Medically Necessary to replace a specific documented deficiency. Prior Authorization is required.  • Nutritional supplements administered by injection at the Practitioner’s/Provider’s office are Covered when Medically Necessary.  • Enteral formulas or products, as Nutritional support, are Covered only when prescribed by an In-network Practitioner/Provider and administered by enteral tube feedings.  • Total Parenteral Nutrition (TPN) is the administration of nutrients through intravenous catheters via central or peripheral veins and is Covered when ordered by an In-network Practitioner/Provider.  • Special Medical Foods as listed as Covered benefits in the Genetic Inborn Errors of  ⮚ Outpatient Medical Services

Prior Auth Required. o 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. The Behavioral Health Practitioner/Provider 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, when required. Please refer to the o In all cases, treatmen treatment must be Medically Necessary in order to be Covered. o Acute Medical Detoxification Benefits are Covered under Inpatient and Outpatient Hospital Services found in the Benefits Section of this Agreement. Inpatient Hospital Services must be Prior Authorized.  Nutritional Support and Suppl ments  Nutritional Supplements for prenatal care when prescribed by a Practitioner/Provider are Covered for regnant pregnant women.  Nutritional supplements that require a prescription to be dispensed are Covered when prescribed by an In-network a Practitioner/Provider and when Medically Necessary to replace a specific documented deficiency. Prior Authorization is required.  Nutritional supplements administered by injection at the Practitioner’sPractitioner/Provider’s office are Covered when Medically Necessary.  Enteral formulas or products, as Nutritional supportSupport, are Covered only when prescribed by an In-network a Practitioner/Provider and administered by enteral tube feedings.  Total Parenteral Nutrition (TPN) is the administration of nutrients through intravenous catheters via central Practitioner/Provider. or peripheral veins and is Covered when ordered by an In-network Practitioner/Provider. a  Special Medical Foods as listed as Covered benefits in the Genetic Inborn Errors of Metabolism (IEM) Benefit of this Section. Prior Authorization is required.  Outpatient Medical ServicesServices Outpatient Medical Services are services provided in a Hospital, Outpatient facility, Practitioner/Provider’s office or other appropriately licensed facility. These services do not require admission to any facility. O ( utpatient Medical services include reasonable Hospital services provided on an ambulatory outpatient) basis, and those diagnostic and treatment procedures that are prescribed by your ttending Practitioner/Provider. Refer to the Prior Authorization Section for services that require Prior Authorization. py and radiation therapy. Chemotherapy is the use of chemical agents in the control of disease.   Hypnotherapy (Limited) - Hypnotherapy is only Covered when performed by an o Used within two weeks prior to surgery for chronic pain management and o For chronic pain management when part of a coordinated treatment plan.  Dialysis  Diagnostic Services – Refer to the Diagnostic Services section  Acute Medical Detoxification: Medically Necessary Services for detoxification Substance Abuse  Medical Drugs (Medications obtained through the medical benefit). Medical Drugs are defined as medications administered in the office or facility that require a Health Care Professional to administer. These medications include, all drugs and routes of administration provided or administered in an out-patient setting. They may involve unique distribution and may be required to be obtained from our specialty pharmacy vendor. Some Medical Drugs may require Prior Authorization before they can be Office administered applies to all outpatient settings including, but not limited to, physician’s offices, emergency rooms, Urgent surgery facilities. For a complete list of Medical Drugs Care Center and outpatient to determine which require Prior Authorization and what drugs are mandated to our Specialty Pharmacy, please see xxxx://xxx.xxx.xxx/idc/groups/public/@phs.@php/documents/phscontent/pel_000 52739.pdf These drugs may be subject to a separate Copayment to a maximum as outlined in your