Common use of Prior Authorization of Services Clause in Contracts

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. ‌ 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 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.