Common use of Prior Authorization of Services Clause in Contracts

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. 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 Care Provider that the service has received Prior Authorization. If you are unable to secure verification from your Health ProfessionalCare Provider, 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;