Prior Authorization of Services a. Members must remember that services provided or received without Prior Authorization from AvMed when authorization is required, are not covered except when required to treat an Emergency Medical Condition. Furthermore, if an inpatient admission is extended beyond the number of days initially approved, without Prior Authorization for the continued stay, it may result in services not being covered. Before a service is performed, you should verify with your Health Professional that the service has received Prior Authorization. If you are unable to secure verification from your Health Professional, you may also call AvMed at 0-000-000-0000.
b. Services that require Prior Authorization from AvMed include:
i. inpatient admissions (including Hospital and observation stays, Skilled Nursing Facilities, ventilator dependent care, acute rehabilitation and inpatient mental health or substance abuse services including Residential Treatment);
ii. surgical procedures or services performed in an outpatient Hospital or Ambulatory Surgery Center; iii. complex diagnostic and therapeutic, and sub-specialty procedures (including CT, CTA, MRI, MRA, PET, and nuclear medicine) and psychological and neuropsychological testing;
Prior Authorization of Services a. If your Health Care Provider is an In-Network Provider, he or she will handle all authorizations, notifications and utilization reviews with AvMed. If your Health Care Provider is a Non- Participating Provider, you are responsible for making sure he or she contacts AvMed to obtain Prior Authorization for a Covered Service when it is required. Please refer to your AvMed Identification Card for the telephone number where authorization may be obtained, or have your Health Professional call 0-000-000-0000.
b. Members must remember that services provided or received without Prior Authorization from AvMed when authorization is required, are not covered except when required to treat an Emergency Medical Condition. Furthermore, if an inpatient admission is extended beyond the number of days initially approved, without Prior Authorization for the continued stay, it may result in services not being covered. Before a service is performed, you should verify with your Health Professional that the service has received Prior Authorization. If you are unable to secure verification from your Health Professional, you may also call AvMed at 0-000-000-0000.
c. Services that require Prior Authorization from AvMed include:
i. inpatient admissions (including Hospital and observation stays, Skilled Nursing Facilities, ventilator dependent care, acute rehabilitation and inpatient mental health or substance abuse services including Residential Treatment);
ii. surgical procedures or services performed in an outpatient Hospital or Ambulatory Surgery Center; iii. complex diagnostic and therapeutic, and sub-specialty procedures (including CT, CTA, MRI, MRA, PET, and nuclear medicine) and psychological and neuropsychological testing;
Prior Authorization of Services. Prior Authorization by Company for Dental Services shall be required when any Treatment Plan and/or treatments exceed Five Hundred Dollars ($500).
Prior Authorization of Services. If we require prior authorization of a service, the following rules apply: • If the service is ordered by a Network Provider, the Network Provider is responsible for prior authorizing the service with us. If the Network Provider does not prior authorize the service with us, we will cover the service with no reduction in benefits to you. • If the service is ordered by a Non-Network Provider, you or the Non-Network Provider are responsible for prior authorizing the service with us. If you or the Non-Network Provider do not prior authorize the service with us, the service will be subject to a retrospective review to see if it meets the definition of medically necessary care. If it is determined to be medically necessary, it will be covered at the non-network benefit level. If it is determined to be not medically necessary, you will be responsible for the cost of the service If you received prior authorization for services under the prior plan, we will accept that prior authorization for the first sixty days of coverage under this plan. You can find the list of services that require prior authorization at xxxxxxxxxxxxxx.xxx ACCESS TO RECORDS AND CONFIDENTIALITY We comply with the state and federal laws governing the confidentiality and use of protected health information and medical or dental records. When your provider releases health information to us according to state law, we can use your protected health information when necessary, for certain health care operations, including, but not limited to: claims processing, including claims we make for reimbursement or subrogation; quality of care assessment and improvement; accreditation, credentialing, case management; care coordination and utilization management, disease management, the evaluation of potential or actual claims against us, auditing and legal services, and other health care operations. When you enrolled for coverage, you authorized our access to use your records as described in this paragraph, and this authorization remains in effect unless it is revoked.
Prior Authorization of Services a. Members must remember that services provided or received without Prior Authorization from AvMed when authorization is required, are not covered except when required to treat an Emergency Medical Condition. Furthermore, if an inpatient admission is extended beyond the number of days initially approved, without Prior Authorization for the continued stay, it may result in services not being covered. Before a service is performed, you should verify with your Health Professional that the service has received Prior Authorization. If you are unable to secure verification from your Health Professional, you may also call AvMed at 0-000-000-0000.
b. Services that require Prior Authorization from AvMed include:
i. inpatient admissions (including Hospital and observation stays, Skilled Nursing Facilities, ventilator dependent care, acute rehabilitation and inpatient mental health or substance abuse services including Residential Treatment);
ii. surgical procedures or services performed in an outpatient Hospital or Ambulatory Surgery Center;
iii. complex diagnostic and therapeutic, and sub-specialty procedures (including CT, CTA, MRI, MRA, PET, and nuclear medicine) and psychological and neuropsychological testing;
iv. Partial Hospitalization and Intensive Outpatient Treatment;
v. Pain Management and outpatient Detoxification;
vi. radiation oncology;
vii. certain medications including Injectable Medications, and select medications administered in a Physician’s office, an outpatient Hospital or infusion therapy setting;
viii. Home Health Care Services;
ix. cardiac rehabilitation;
x. dialysis services;
xi. transplant services;
xii. non-emergency transport services;
xiii. care rendered by Non-Participating Providers (except for Emergency Medical Services and Care).
c. Services requiring Prior Authorization may change from time to time. For more information about which services require Prior Authorization, contact XxXxx’s Member Engagement Center at 0- 000-000-0000. You should always make sure your Physician contacts us to obtain Prior Authorization.
Prior Authorization of Services a. Members must remember that services provided or received without Prior Authorization from AvMed when authorization is required, are not covered except when required to treat an Emergency Medical Condition. Furthermore, if an inpatient admission is extended beyond the number of days initially approved, without Prior Authorization for the continued stay, it may result in services not being covered. Before a service is performed, you should verify with your Health Professional that the service has received Prior Authorization. If you are unable to secure verification from your Health Professional, you may also call AvMed at 0-000-000-0000.
b. Services that require Prior Authorization from AvMed include:
i. inpatient admissions (including Hospital and observation stays, Skilled Nursing Facilities, ventilator dependent care, acute rehabilitation and inpatient mental health or substance abuse services including Residential Treatment);
ii. surgical procedures or services performed in an outpatient Hospital or Ambulatory Surgery Center;
iii. complex diagnostic and therapeutic, and sub-specialty procedures (including CT, CTA, MRI, MRA, PET, and nuclear medicine) and psychological and neuropsychological testing;
iv. Partial Hospitalization and Intensive Outpatient Treatment;
v. Pain Management and outpatient detoxification; vi. radiation oncology;
Prior Authorization of Services
