Common use of Prior Authorization Recommendation Clause in Contracts

Prior Authorization Recommendation. XXX recommends that you or your provider request prior authorization for certain services to determine whether they are medically necessary. When a participating provider renders services, the provider will obtain authorization in advance from PIC for you by following the procedures explained in this section of this contract. It is your responsibility to obtain prior authorization from PIC, and follow the procedures in this section of this contract when you receive services from non-participating providers. Non-participating provider benefits are not available for the services listed in items 2, 4 and 7 below. If you have questions about prior authorization, please contact PIC Customer Service. Pre-certification penalties do not apply. You and your provider should follow the same procedures for prior authorization as you follow for pre-certification with respect to obtaining services and submitting an appeal. The prior authorization process is recommended for a variety of services including but not limited to those listed below, and others that are listed in PIC’s “Prior Authorization List” which you can access via the “Medical Policy” link on your member home page at xxx.xxxxxxxxxxxx.xxx: