Prior Authorization and Pre-Certification. 4.11.2.1 The Contractor shall not require Prior Authorization or Pre-Certification for Emergency Services, Post-Stabilization Services, or Urgent Care services, as described in Section 4.6.1, 4.6.2, and 4.6.3. 4.11.2.2 The Contractor shall require Prior Authorization and/or Pre-Certification for all non-emergent and non-urgent inpatient admissions except for normal newborn deliveries. 4.11.2.3 The Contractor may require Prior Authorization and/or Pre-Certification for all non-emergent, Out-of-Network services. 4.11.2.4 Prior Authorization and Pre-Certification shall be conducted by a currently licensed, registered or certified Health Care Professional who is appropriately trained in the principles, procedures and standards of Utilization Review. 4.11.2.5 The Contractor shall notify the Provider of Prior Authorization determinations in accordance with the following timeframes:
Appears in 8 contracts
Samples: Contract for Provision of Services, Contract for Provision of Services (Wellcare Health Plans, Inc.), Contract for Provision of Services (Wellcare Health Plans, Inc.)
