Common use of Prior Authorization and Referrals Clause in Contracts

Prior Authorization and Referrals. PPG and Member Physicians agree to comply with prior authorization and referral processes as required by the particular Benefit Program or Utilization/Care Management Program as set forth in the Operations Manual. In the event PPG agrees to participate in a program offered by another health plan, preferred provider organization, managed care organization, or insurer which includes an expedited process for referrals or authorizations, PPG agrees to participate in and offer the same access for FHS Members for any such program offered by FHS. Prior authorizations or referrals may be issued by FHS, PPG, a Participating Provider, or Member Physician in accordance with the applicable Benefit Program. For non-emergent services, PPG or Participating Provider agrees to obtain prior authorization or a referral before providing or ordering Covered Services if required by the applicable Benefit Program. In an Emergency, PPG agrees to attempt to obtain prior authorization or a referral, by telephone if necessary, before providing or ordering Covered Services. If prior authorization or a referral cannot be obtained, PPG agrees to notify FHS and the appropriate Participating Provider, as soon as possible, but no later than twenty-four (24) hours after admission. In the even PPG fails to obtain an authorization or a referral, PPG agrees not to seek payment from FHS or a Payor for Contracted Services rendered to a Member unless prior authorization or a referral was obtained. FHS shall retain the right to authorize Emergency services in accordance with the Operations Manual.

Prior Authorization and Referrals. PPG and Member Physicians agree to comply with prior authorization and referral processes as required by the particular Benefit Program or Utilization/Care Management Program as set forth in the Operations Manual. In the event PPG agrees to participate in a program offered by another health plan, preferred provider organization, managed care organization, or insurer which includes an expedited process for referrals or authorizations, PPG agrees to participate in and offer the same access for FHS Members for any such program offered by FHS. Prior authorizations or referrals may be issued by FHS, PPG, a Participating Provider, or Member Physician in accordance with the applicable Benefit Program. For non-emergent services, PPG or Participating Provider agrees to obtain prior authorization or a referral before providing or ordering Covered Services if required by the applicable Benefit Program. In an Emergency, PPG agrees to attempt to obtain prior authorization or a referral, by telephone if necessary, before providing or ordering Covered Services. If prior authorization or a referral cannot be obtainedobtained in an Emergency, PPG agrees to notify FHS and the appropriate Participating Provider, as soon as possible, but no later than twenty-four (24) hours after admission. In the even event PPG fails to obtain an authorization or a referral, PPG agrees not to seek payment from FHS or a Payor for Contracted Services rendered to a Member unless prior authorization or a referral was obtained. FHS shall retain the right to authorize Emergency services in accordance with the Operations Manual.

Prior Authorization and Referrals. PPG and Member Physicians agree to comply with prior authorization and referral processes as required by the particular Benefit Program or Utilization/Care Management Program as set forth in the Operations Manual. In the event PPG agrees to participate in a program offered by another health plan, preferred provider organization, managed care organization, or insurer which includes an expedited process for referrals or authorizations, PPG agrees to participate in and offer the same access for FHS HNI Members for any such program offered by FHSHNI. Prior authorizations or referrals may be issued by FHSHNI, PPG, a Participating Provider, or Member Physician in accordance with the applicable Benefit Program. For non-emergent services, PPG or Participating Provider agrees to obtain prior authorization or a referral before providing or ordering Covered Services if required by the applicable Benefit Program. In an Emergency, PPG agrees to attempt to obtain prior authorization or a referral, by telephone if necessary, before providing or ordering Covered Services. If prior authorization or a referral cannot be obtainedobtained in an Emergency, PPG agrees to notify FHS HNI and the appropriate Participating Provider, as soon as possible, but no later than twenty-four (24) hours after admission. In the even event PPG fails to obtain an authorization or a referral, PPG agrees not to seek payment from FHS HNI or a Payor for Contracted Services rendered to a Member unless prior authorization or a referral was obtained. FHS shall retain the right to authorize Emergency services in accordance with the Operations Manual.

Prior Authorization and Referrals. PPG and Member Physicians agree to comply with prior authorization and referral processes as required by the particular Benefit Program or Utilization/Care Management Program as set forth in the Operations Manual. In the event PPG agrees to participate in a program offered by another health plan, preferred provider organization, managed care organization, or insurer which includes an expedited process for referrals or authorizations, PPG agrees to participate in and offer the same access for FHS Members for any such program offered by FHS. Prior authorizations or referrals may be issued by FHS, PPG, a Participating Provider, or Member Physician in accordance with the applicable Benefit Program. For non-emergent services, PPG or Participating Provider agrees to obtain prior authorization or of a referral before providing or ordering Covered Services if required by the applicable Benefit Program. In an Emergency, PPG agrees to attempt to obtain prior authorization or a referral, by telephone if necessary, before providing or ordering Covered Services. If prior authorization or a referral cannot be he obtained, PPG agrees to notify FHS and the appropriate Participating Provider, as soon as possible, but no later than twenty-four (24) hours after admission. In the even PPG fails to obtain an authorization or of a referral, PPG agrees not to seek payment from FHS or a Payor for Contracted Services rendered to a Member unless prior authorization or of a referral was obtained. FHS shall retain the right to authorize Emergency services in accordance with the Operations Manual.

Prior Authorization and Referrals. PPG and Member Physicians agree to comply with prior authorization and referral processes as required by the particular Benefit Program or Utilization/Care Management Program as set forth in the Operations Manual. In the event PPG agrees to participate in a program offered by another health plan, preferred provider organization, managed care organization, or insurer which includes an expedited process for referrals or authorizations, PPG agrees to participate in and offer the same access for FHS Members for any such program offered by FHS. Prior authorizations or referrals may be issued by FHS, PPG, a Participating Provider, or Member Physician in accordance with the applicable Benefit Program. For non-emergent services, PPG or Participating Provider agrees to obtain prior authorization or a referral before providing or ordering Covered Services if required by the applicable Benefit Program. In an Emergency, PPG agrees to attempt to obtain prior authorization or a referral, by telephone if necessary, before providing or ordering Covered Services. If prior authorization or a referral cannot be obtained, PPG agrees to notify FHS and the appropriate Participating Provider, as soon as possible, but no later than twenty-twenty four (24) hours after admission. In the even event PPG fails to obtain an authorization or a referral, referral PPG agrees not to seek payment from FHS or a Payor for Contracted Services rendered to a Member unless prior authorization or a referral was obtained. FHS shall retain the right to authorize Emergency services in accordance with the Operations Manual.