Prior Authorization. A determination to authorize a Provider’s request, pursuant to services covered in the MississippiCAN Program, to provide a service or course of treatment of a specific duration and scope to a Member prior to the initiation or continuation of the service.
Prior Authorization. Have the ability to require Prior Authorization on medications to ensure appropriate use and to encourage the use of preferred medications.
4.2.21.3.1. The CONTRACTOR must provide a response to requests for Prior Authorization within 24 hours of the request.
4.2.21.3.2. Per 42 U.S.C 1396r 8(d)(5)(B) and 42 CFR 438.3(s)
Prior Authorization. Prior authorization allows the Member and provider to verify with Blue Shield or Blue Shield’s MHSA that (1) the proposed services are a Benefit of the Member’s plan, (2) the proposed services are Medically Necessary, and (3) the proposed setting is clinically appropriate. The prior authorization process also informs the Member and provider when Benefits are limited to services rendered by Participating Providers or MHSA Participating Providers (See the Summary of Benefits). A decision will be made on all requests for prior authorization within five business days from receipt of the request. The treating provider will be notified of the decision within 24 hours and written notice will be sent to the Member and provider within two business days of the decision. For urgent services when the routine decision making process might seriously jeopardize the life or health of a Member or when the Member is experiencing severe pain, a decision will be rendered as soon as possible to accommodate the Member’s condition, not to exceed 72 hours from receipt of the request. (See the Outpatient Prescription Drug Benefits section for specific information about prior authorization for outpatient prescription drugs). If prior authorization was not obtained, and services provided to the Member are determined not to be a Benefit of the plan or were not medically necessary, coverage will be denied. Prior authorization is required for radiological and nuclear imaging procedures. The Member or provider should call 0-000-000-0000 for prior authorization of the following radiological and nuclear imaging procedures when performed within California on an outpatient, non-emergency basis:
Prior Authorization. County shall provide to Contractor written prior authorization for each patient admitted. A patient may be admitted without a completed authorization form on the basis of verbal authorization from the county contract liaison by mutual consent of the County and Contractor, provided County supplies a completed authorization within three (3) days from the date of admission.
Prior Authorization. This means a determination by our medical directors, or their designees, that an admission, extension of stay, or other health care service has been reviewed and that, based on the information provided, it satisfies our utilization review requirements. We will then pay for the covered benefit, provided the general exclusion provisions, and any deductible, copayment, coinsurance, or other policy requirements have been met. Reconstructive Surgery. This is limited to reconstructive surgery, incidental to or following surgery, resulting from injury or illness of the involved part, or to correct a congenital disease or anomaly resulting in functional defect in a dependent child, as determined by the attending physician.
Prior Authorization.
a) HCWs/PSWs may not be paid for hours that are not prior authorized. Prior authorization for APD is the SDS 4105, or the task list and voucher. Prior authorization for ODDS services is when the individual has an authorized Individual Support Plan (ISP), there is service level agreement describing the support to be provided that has been signed by the Consumer/common law Employer and PSW, and there is authorization for services in eXPRS Plan of Care. Prior authorization for OHA services is considered the voucher.
b) In the case of an emergency or urgent situation that occurs after local office hours, the HCW/PSW must notify the case manager or service plan coordinator within two (2) business days.
Prior Authorization. Certain prescription drugs may require prior authorization before you can have your prescription filled at the pharmacy. For information, you may call PIC at the phone number listed on the inside front cover of this contract. These prescription drugs may include, but are not limited to:
Prior Authorization. Prior Authorization is a process that helps ensure the appropriate use of Specialty prescription drugs. This program is designed to promote a step wise approach of treatment (use of Drug A before using Drug B), manage the risk of drugs with serious side effects and positively influence the process for managing drug costs.
Prior Authorization. Step Therapy (trial of a lower cost drug before a higher cost drug is covered).
Prior Authorization. Except for Emergency Services or where prior authorization is not required by the Provider Manual, Providers shall obtain prior authorization for Covered Services in accordance with the Provider Manual. Except where not permitted by Laws or Program Requirements, Health Plan may deny payment for Covered Services where a Provider fails to meet Health Plan’s requirements for prior authorization.
