Common use of Prior Auth Required Clause in Contracts

Prior Auth Required. o Maternity Coverage is available to a mother and her newborn (if a Member) for at least 48 hours of Inpatient care following a vaginal delivery and at least 96 hours of Inpatient care following a cesarean section. Maternity In-patient Hospital admissions and birthing center admissions require Prior Authorization. o In the event that the mother requests an earlier discharge, a mutual agreement must be reached between the mother and her attending Practitioner/Provider. Such discharge must be made in accordance with the medical criteria outlined in the most current version of the “Guid lines for Prenatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists including, but not limited to, the criterion that family Members or other support person(s) will be available to the mother for the first few days following early discharge. o Maternity Inpatient care in excess of 48 hours following a vaginal delivery and 96 hours following a cesarean section will be Covered if determined to be Medically Necessary by the mother’s attending Practitioner/Provider. An additional stay will be considered a separate Hospital stay and requires Prior Authorization. Refer to your Summary of Benefits and Coverage for Cost Sharing information. o High-risk Ambulance services are Covered in accordance with the Ambulance o The services of a Midwife or Certified Nurse Midwife are Covered, for the following: ♦ The midwife’s services must be provided strictly according to their legal scope of practice and in accordance with all applicable state licensing regulations which may include a supervisory component. ♦ The services must be provided in preparation for delivery of a newborn. or in connection with the ♦ For purpose of Coverage under this Agreement, the only allowable sites of delivery are a Hospital or a licensed birthing center. Elective Home Births and any prenatal or postpartum services connected with Elective Home Births are not Covered. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home. combined fees of the midwife and any attending or supervising Practitioners/Providers, for all services provided before, during and after the birth, not exceed the allowable fee(s) that would have been payable to the Practitioner/Provider had he/she been services.  Newborn Care the sole Practitioner/Provider of those o A newborn of a Member will be Covered from the moment of birth when enrolled as follows: ♦ Your newborn or the newborn of your Spouse will be Covered from the moment of birth if we receive the signed and completed Dependent Form within 31 days from the date of birth. Dependent Form is not received newborn is not eligible for family coverage. You may apply for a qualifying product through a separate Enrollment Application Form, which will be subject to medical underwriting. ♦ If the above conditions are not met, we will not enroll the newborn for Coverage until the next Annual Enrollment Period. ♦ Neonatal care is available for the newborn of a Member for at least 48 hours of Inpatient care following a vaginal delivery and at least 96 hours of Inpatient care following a Cesarean section. If the mother is discharged from the Hospital and the newborn rem ins in the Hospital, it is considered a separate Hospital stay and requires Prior Authorization. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. ♦ Benefits for a newborn who is a Member shall include Coverage for injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. Where necessary to protect the life of the infant Coverage includes transportation, including air Ambulance Services to the nearest available Tertiary facility. Newborn Member benefits also include Coverage for newborn visits in the Hospital by the baby’s Practitioner/Provider, circumcision, incubator, and routine Hospital nursery charges. ♦ A newborn of a Member’s Dependent child cannot be enrolled unless the newborn is legally adopted by the Subscriber, or the Subscriber is appointed by the court as the newborn’s legal guardian.  Additional

Prior Auth Required. o Midwife o Medically Necessary nutritional supplements as determined and prescribed by the attending Practitioner/Provider Prescription nutritional supplements require o Childbirth in a Hospital or in a licensed birthing center  Maternity care o Maternity Coverage is available to a mother and her newborn (if a Member) for at least 48 hours of Inpatient care following a vaginal delivery and at least 96 hours of Inpatient care following a cesarean section. Maternity In-patient Hospital admissions and birthing center admissions require Prior Authorization. o In the event that the mother requests an earlier discharge, a mutual agreement must be reached between the mother and her attending Practitioner/Provider. Such discharge must be made in accordance with the medical criteria outlined in the most current version of the “Guid lines Guidelines for Prenatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists including, but not limited to, the criterion that family Members or other support person(s) will following early discharge. be available to the mother for the first few days following early discharge. o Maternity Inpatient care in excess of 48 hours following a vaginal delivery and 96 hours following a cesarean section will be Covered if determined to be Medically Necessary by the mother’s attending Practitioner/Provider. An additional stay will be considered a separate Hospital stay and requires Prior Authorization. Refer to your Summary of Benefits and Coverage for Cost Sharing information. o High-risk Ambulance services are Covered in accordance with the Ambulance o The services of a following: Midwife or Certified Nurse Midwife are Covered, for the following: ♦ The midwife’s services must be provided strictly according to their legal scope of practice ractice and in accordance with all applicable state licensing regulations which may include a supervisory component. ♦ The services must be provided in preparation for or in connection with the delivery of a newborn. or in connection with the ♦ For purpose of Coverage under this Agreement, the only allowable sites of delivery are a Hospital or a licensed birthing center. Elective Home Births and any prenatal or postpartum services connected with Elective Home Births are not Covered. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home. combined fees of the midwife and any attending or supervising Practitioners/Providers, for all services provided before, during and after the birth, may not exceed the allowable fee(s) that would have been payable to the Practitioner/Provider had he/she been services.  Newborn Care the sole Practitioner/Provider of those  Newborn o A newborn of a Member will be Covered from the moment of birth when enrolled as follows: ♦ Your newborn or the newborn of your Spouse will be Covered from the moment of birth if we We must receive the signed and completed Dependent Form enrollment Application for the newborn that was submitted to the employer Group within 31 days from the date of birth. Dependent Form is not received ♦ If enrollment of a newborn is not eligible for family coverage. You may apply for a qualifying product through a separate Enrollment results in an increase to the amount of Prepayment able Prepayment must be paid with the signed enrollment Application Form, which will be subject to medical underwritingwithin the first 31 days following the date of birth. ♦ If the above conditions are not met, we will not enroll the newborn for Coverage until the next Annual Group Enrollment Period. ♦ Neonatal care is available for the newborn of a Member for at least 48 hours of Inpatient care following a vaginal delivery and at least 96 hours of Inpatient care following a Cesarean section. If the mother is discharged from the Hospital and the newborn rem ins remains in the Hospital, it is considered a separate Hospital stay and requires Prior Authorization. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. ♦ Benefits for a newborn who is a Member shall include Coverage for injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. Where necessary to protect the life of the infant Coverage includes transportation, including air Ambulance Services to the nearest available Tertiary facility. Newborn Member benefits also include Coverage for newborn visits in the Hospital by the baby’s Practitioner/Provider, circumcision, incubator, and routine Hospital nursery charges. ♦ A newborn of a Member’s Dependent child cannot be enrolled unless the newborn is legally adopted by the Subscriber, or the Subscriber is appointed by the court as the newborn’s legal guardian.  Additionalto

Prior Auth Required. o Maternity Coverage is available to a mother and her newborn (if a Member) for at least 48 hours of Inpatient care following a vaginal delivery and at least 96 hours of Inpatient care following a cesarean section. Maternity In-patient Hospital admissions and birthing center admissions require Prior Authorization. o In the event that the mother requests an earlier discharge, a mutual agreement must be reached between the mother and her attending Practitioner/Provider. Such discharge must be made in accordance with the medical criteria outlined in the most current version of the “Guid lines for Prenatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists including, but not limited to, the criterion that family Members or other support person(s) will be available to the mother for the first few days following early discharge. o Maternity Inpatient care in excess of 48 hours following a vaginal delivery and 96 hours following a cesarean section will be Covered if determined to be Medically Necessary by the mother’s attending Practitioner/Provider. An additional stay will be considered a separate Hospital stay and requires Prior Authorization. Refer to your Summary of Benefits and Coverage for Cost Sharing information. o High-risk Ambulance services are Covered in accordance with the Ambulance o The services of a Midwife or Certified Nurse Midwife are Covered, for the following: ♦ The midwife’s services must be provided strictly according to their legal scope of practice and in accordance with all applicable state licensing regulations which may include a supervisory component. ♦ The services must be provided in preparation for delivery of a newborn. or in connection with the ♦ For purpose of Coverage under this Agreement, the only allowable sites of delivery are a Hospital or a licensed birthing center. Elective Home Births and any prenatal or postpartum services connected with Elective Home Births are not Covered. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home. combined fees of the midwife and any attending or supervising Practitioners/Providers, for all services provided before, during and after the birth, not exceed the allowable fee(s) that would have been payable to the Practitioner/Provider had he/she been services.  Newborn Care the sole Practitioner/Provider of those o A newborn of a Member will be Covered from the moment of birth when enrolled as follows: ♦  Your newborn or the newborn of your Spouse will be Covered from the moment of birth if we receive the signed and completed Dependent Form within 31 days from the date of birth. Dependent Form is not received newborn is not eligible for family coverage. You may apply for a qualifying product through a separate Enrollment Application Form, which will be subject to medical underwriting. ♦ If the above conditions are not met, we will not enroll the newborn for Coverage until the next Annual Enrollment Period. ♦ Neonatal care is available for the newborn of a Member for at least 48 hours of Inpatient care following a vaginal delivery and at least 96 hours of Inpatient care following a Cesarean section. If the mother is discharged from the Hospital and the newborn rem ins in the Hospital, it is considered a separate Hospital stay and requires Prior Authorization. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. ♦ Benefits for a newborn who is a Member shall include Coverage for injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. Where necessary to protect the life of the infant Coverage includes transportation, including air Ambulance Services to the nearest available Tertiary facility. Newborn Member benefits also include Coverage for newborn visits in the Hospital by the baby’s Practitioner/Provider, circumcision, incubator, and routine Hospital nursery charges. ♦ A newborn of a Member’s Dependent child cannot be enrolled unless the newborn is legally adopted by the Subscriber, or the Subscriber is appointed by the court as the newborn’s legal guardian.  Additional

Prior Auth Required. o Maternity Coverage is available to a mother and her newborn (if a Member) for at least 48 hours of Inpatient care following a vaginal delivery and at least 96 hours of Inpatient care following a cesarean section. Maternity In-patient Hospital admissions and birthing center admissions require Prior Authorization. o In the event that the mother requests an earlier discharge, a mutual agreement must be reached between the mother and her attending Practitioner/Provider. Such discharge must be made in accordance with the medical criteria outlined in the most current version of the “Guid lines for Prenatal Care” prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists including, but not limited to, the criterion that family Members or other support person(s) will be available to the mother for the first few days following early discharge. o Maternity Inpatient care in excess of 48 hours following a vaginal delivery and 96 hours following a cesarean section will be Covered if determined to be Medically Necessary by the mother’s attending Practitioner/Provider. An additional stay will be considered a separate Hospital stay and requires Prior Authorization. Refer to your Summary of Benefits and Coverage for Cost Sharing information. o High-risk Ambulance services are Covered in accordance with the Ambulance o The services of a Midwife or Certified Nurse Midwife are Covered, for the following: ♦ The midwife’s services must be provided strictly according to their legal scope of practice and in accordance with all applicable state licensing regulations which may include a supervisory component. ♦ The services must be provided in preparation for delivery of a newborn. or in connection with the ♦ For purpose of Coverage under this Agreement, the only allowable sites of delivery are a Hospital or a licensed birthing center. Elective Home Births and any prenatal or postpartum services connected with Elective Home Births are not Covered. Elective Home Birth means a birth that was planned or intended by the Member or Practitioner/Provider to occur in the home. combined fees of the midwife and any attending or supervising Practitioners/Providers, for all services provided before, during and after the birth, not exceed the allowable fee(s) that would have been payable to the Practitioner/Provider had he/she been services.  • Newborn Care the sole Practitioner/Provider of those o A newborn of a Member will be Covered from the moment of birth when enrolled as follows: ♦ ⬩ Your newborn or the newborn of your Spouse will be Covered from the moment of birth if we receive the signed and completed Dependent Form within 31 days from the date of birth. Dependent Form is not received newborn is not eligible for family coverage. You may apply for a qualifying product through a separate Enrollment Application Form, which will be subject to medical underwriting. ♦ If the above conditions are not met, we will not enroll the newborn for Coverage until the next Annual Enrollment Period. ♦ Neonatal care is available for the newborn of a Member for at least 48 hours of Inpatient care following a vaginal delivery and at least 96 hours of Inpatient care following a Cesarean section. If the mother is discharged from the Hospital and the newborn rem ins in the Hospital, it is considered a separate Hospital stay and requires Prior Authorization. Refer to your Summary of Benefits and Coverage for your Cost Sharing amount. ♦ Benefits for a newborn who is a Member shall include Coverage for injury or sickness including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities. Where necessary to protect the life of the infant Coverage includes transportation, including air Ambulance Services to the nearest available Tertiary facility. Newborn Member benefits also include Coverage for newborn visits in the Hospital by the baby’s Practitioner/Provider, circumcision, incubator, and routine Hospital nursery charges. ♦ A newborn of a Member’s Dependent child cannot be enrolled unless the newborn is legally adopted by the Subscriber, or the Subscriber is appointed by the court as the newborn’s legal guardian.  • Additional