Prior Authorization Requirement Sample Clauses

Prior Authorization Requirement. All transplant procedures must be Prior Authorized for type of transplant and be Medically Necessary and not Experimental or Investigational according to criteria established by Alliant. To Prior Authorize, call (000) 000-0000. The Prior Authorization requirements are a part of the benefit administration of the Contract and are not a treatment recommendation. The actual course of medical treatment the Member chooses remains strictly a matter between the Member and his or her Physician. Your Physician must submit a complete medical history, including current diagnosis and name of the surgeon who will perform the transplant. The surgery must be performed at an Alliant-approved transplant center. The donor, donor recipient, and the transplant surgery must meet required medical selection criteria as defined by Alliant. If the transplant involves a living donor, benefits are as follows: • If a Member receives a transplant and the donor is also covered under this Contract, payment for the Member and the donor will be made under each Member’s Coverage. • If the donor is not covered under this Contract, payment for the Member and the donor will be made under this Contract but will be limited by any payment which might be made under any other hospitalization coverage plan. • If the Member is the donor and the recipient is not covered under this Contract, payment for the Member will be made under this Contract limited by any payment which might be made by the recipient’s hospitalization coverage with another company. No payment will be made under this Contract for the recipient. Covered Services rendered at Urgent Care Centers are paid as outlined in the Summary of Benefits and Coverage. Urgent Care means any medical care or treatment of a medical condition that (A) could seriously jeopardize your life or health or your ability to regain maximum function or (B) in the opinion of the attending Provider, would subject you to severe pain that cannot be adequately managed without care or treatment. Treatment of an Urgent Care medical problem is not life threatening and does not require use of an emergency room at a Hospital; and is not considered an emergency. (Be aware that large group plans are not required to offer out-patient Prescription Drug benefits; verify coverage with your Human Resources Department if you are a member of a large group account.) This Plan uses a Pharmacy Benefits Manager (PBM) for the administration of out-patient prescription drug benefits. M...
Sample 1See All (7)
Prior Authorization Requirement. Certain types of care require Prior Authorization by us. This means that you or your Provider must ask us to approve the care before you receive it. A complete and current list of the services subject to Prior Authorization can be found here: The prescription drugs that are subject to a Prior Authorization requirement can be found at xxxx://xxxx.xxx.xxx/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001476. pdf. We may decline payment for unauthorized care. If your Provider is In-network, and you did not agree to receive unauthorized care, your Provider cannot bill you for the care. If you received unauthorized care from a Provider who is not In-network you may be fully responsible for the resulting bills. We do not require Prior Authorization for: Mental health or substance use disorder services: o Acute or immediately necessary care; o Acute episodes of chronic mental health or substance use disorder conditions; o Initial in-network inpatient or outpatient substance use treatment services. Prescription drugs used for the treatment of substance use disorders, when a generic version is available, the medication is medically necessary and is approved by the Federal Food and Drug Administration; Emergency services Contraception services that are not subject to any Cost Sharing Obstetrical or gynecological ultrasound However, we require authorization for continued in-patient care if you are admitted to a Hospital for Emergency treatment, but your condition is stabilized. You or your Provider must notify us as soon as possible from when you begin receiving Emergency in-patient treatment, and within 24 hours after the Emergency ends and your condition stabilizes.
Sample 1Sample 2See All (5)
Prior Authorization Requirement. All transplant procedures must be Prior Authorized for type of transplant and be Medically Necessary and not Experimental or Investigational according to criteria established by Alliant. To Prior Authorize, call (000) 000-0000. The Prior Authorization requirements are a part of the benefit administration of the Contract and are not a treatment recommendation. The actual course of medical treatment the Member chooses remains strictly a matter between the Member and his or her Physician. Your Physician must submit a complete medical history, including current diagnosis and name of the surgeon who will perform the transplant. The surgery must be performed at an Alliant-approved transplant center. The donor, donor recipient, and the transplant surgery must meet required medical selection criteria as defined by Alliant. If the transplant involves a living donor, benefits are as follows: • If a Member receives a transplant and the donor is also covered under this Contract, payment for the Member and the donor will be made under each Member’s Coverage. • If the donor is not covered under this Contract, payment for the Member and the donor will be made under this Contract but will be limited by any payment which might be made under any other hospitalization coverage plan. • If the Member is the donor and the recipient is not covered under this Contract, payment for the Member will be made under this Contract limited by any payment which might be made by the recipient’s hospitalization coverage with another company. No payment will be made under this Contract for the recipient.
Sample 1
Prior Authorization Requirement. Certain types of care require Prior Authorization by us. This means that you or your Provider must ask us to approve the care before you receive it. A complete and current list of the services subject to Prior Authorization can be found here: The prescription drugs that are subject to a Prior Authorization requirement can be found at xxxx://xxxx.xxx.xxx/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001476. pdf. We may decline payment for unauthorized care. If your Provider is In-network, and you did not agree to receive unauthorized care, your Provider cannot bill you for the care. If you received We do not require Prior Authorization for: • Emergency services • Contraception services that are not subject to any Cost Sharing • Obstetrical or gynecological ultrasound
Sample 1
Prior Authorization Requirement. Certain types of care require Prior Authorization by us. This means that you or your Provider must ask us to approve the care before you receive it. A complete and current list of the services subject to Prior Authorization can be found here: xxxx://xxx.xxx.xxx/cs/groups/public/documents/communication/pel_00957159.pdf. The prescription drugs that are subject to a Prior Authorization requirement can be found at xxxx://xxxx.xxx.xxx/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001476. pdf. We may decline payment for unauthorized care. If your Provider is In-network, and you did not agree to receive unauthorized care, your Provider cannot bill you for the care. If you received unauthorized care from a Provider who is not In-network you may be fully responsible for the resulting bills. We do not require Prior Authorization for: • Emergency services; • Contraception services that are not subject to any Cost Sharing; or • Obstetrical or gynecological ultrasound. However, we require authorization for continued in-patient care if you are admitted to a Hospital for Emergency treatment, but your condition is stabilized. You or your Provider must notify us as soon as possible from when you begin receiving Emergency in-patient treatment, and within 24 hours after the Emergency ends and your condition stabilizes.
Sample 1
Prior Authorization Requirement. Certain types of care require Prior Authorization by us. This means that you or your Provider must ask us to approve the care before you receive it. A complete and current list of the services subject to Prior Authorization can be found here: xxxx://xxx.xxx.xxx/cs/groups/public/documents/communication/pel_00957159.pdf. The prescription drugs that are subject to a Prior Authorization requirement can be found at xxxx://xxxx.xxx.xxx/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001476. pdf. We may decline payment for unauthorized care. If your Provider is In-network, and you did not agree to receive unauthorized care, your Provider cannot bill you for the care. If you received unauthorized care from a Provider who is not In-network you may be fully responsible for the resulting bills. We do not require Prior Authorization for: · Emergency services · Contraception services that are not subject to any Cost Sharing · Obstetrical or gynecological ultrasound
Sample 1
Prior Authorization Requirement. Certain types of care require Prior Authorization by us. This means that you or your Provider must ask us to approve the care before you receive it. A complete and current list of the services subject to Prior Authorization can be found here: xxxxx://xxxxxxxxx.xxx.xxx/PEL/DisplayDocument?ContentID=OB_000000002930. The prescription drugs that are subject to a Prior Authorization requirement can be found at xxxx://xxxx.xxx.xxx/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001476. pdf. We may decline payment for unauthorized care. If your Provider is In-network, and you did not agree to receive unauthorized care, your Provider cannot bill you for the care. If you received unauthorized care from a Provider who is not In-network you may be fully responsible for the resulting bills. • Mental health or substance use disorder services: o Acute or immediately necessary care; o Acute episodes of chronic mental health or substance use disorder conditions; o Initial in-network inpatient or outpatient substance use treatment services. • Prescription drugs used for the treatment of substance use disorders, when a generic version is available, the medication is medically necessary and is approved by the Federal Food and Drug Administration; • Emergency services • Contraception services that are not subject to any Cost-Sharing • Obstetrical or gynecological ultrasound
Sample 1
Prior Authorization Requirement. Certain types of care require Prior Authorization by us. This means that you or your Provider must ask us to approve the care before you receive it. A complete and current list of the services subject to Prior Authorization can be found here: The prescription drugs that are subject to a Prior Authorization requirement can be found at xxxx://xxxx.xxx.xxx/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001476. pdf. We may decline payment for unauthorized care. If your Provider is In-network, and you did not agree to receive unauthorized care, your Provider cannot bill you for the care. If you received unauthorized care from a Provider who is not In-network, you may be fully responsible for the resulting bills. We do not require Prior Authorization for:  Mental health or substance use disorder services: o Acute or immediately necessary care; o Acute episodes of chronic mental health or substance use disorder conditions; o Initial in-network inpatient or outpatient substance use treatment services.  Prescription drugs used for the treatment of substance use disorders, when a generic version is available, the medication is medically necessary and is approved by the Federal Food and Drug Administration;  Emergency services  Contraception services that are not subject to any Cost-Sharing  Obstetrical or gynecological ultrasound Your In-network Provider is responsible for knowing what care requires Prior Authorization, and for submitting a Prior Authorization request to us. We will give any Provider access to all necessary forms and instructions for making the request. An Out-of-network Provider is not required to submit a Prior Authorization request for you. If you visit one of these Providers, and that Provider will not submit a Prior Authorization request, you may submit a Prior Authorization request on your own behalf, or on behalf of a Dependent. We will help you obtain required documents and show you the guidelines that apply to the request. However, because your Provider should be able to gather required information and submit it sooner, we encourage you to have your Provider request Prior Authorization whenever possible.
Sample 1
Prior Authorization Requirement. Certain types of care require prior authorization by us.
Sample 1

Related to Prior Authorization Requirement

  • Notification Requirements 1. If the Family Leave is foreseeable, the employee must provide the agency/department with thirty (30) calendar days notice of his or her intent to take Family Leave. 2. If the event necessitating the Family Leave becomes known to the employee less than thirty (30) calendar days prior to the employee's need for Family Leave, the employee must provide as much notice as possible. In no case shall the employee provide notice later than five (5) calendar days after he or she learns of the need for Family Leave. 3. For foreseeable leave due to a qualifying exigency, an employee must provide notice of the need for leave as soon as practicable, regardless of how far in advance such leave is foreseeable. 4. When the Family Leave is for the purpose of the scheduled medical treatment or planned medical care of a child, parent, spouse or registered domestic partner, the employee shall, to the extent practicable, schedule treatment and/or care in a way that minimizes disruption to agency/department operations.

  • Notification Requirement Through and up to the conclusion of the Non-Competition Period, Executive shall give notice to the Company of each new business activity he plans to undertake, at least seven (7) days prior to beginning any such activity. Such notice shall state the name and address of the Person for whom such activity is undertaken and the nature of Executive’s business relationship(s) and position(s) with such Person.

  • Application Requirements This application shall contain, as a minimum, a sketch showing the location of proposed facilities; a description, sketch, manufacturer’s brochure, etc. of the proposed facilities; and a description of the operation proposed. (11-28-90) 101. -- 199. (RESERVED)‌ 200. OPERATIONAL AGREEMENT.‌‌

  • Certification Requirements The applicant will provide Vista Laboratories, Inc. with all product information for the evaluation of the product to be certified and warrant that the information provided is accurate and complete so that Vista Labs may perform the services requested. If the product was tested at an external laboratory, the applicant must provide the complete test report to Vista Labs. If the external testing facility is not ISO 17025 accredited, or does not have the proper scope, Vista Labs must determine if the test report can be used for certification activities. The applicant’s information is used to perform a product review and evaluation to determine the product’s compliance to the specific certification requested. Throughout the process, the client agrees to make claims regarding certification consistent with the scope of certification. The applicant agrees to supply the required number of product samples, to be determined by Vista Labs, to the laboratory for testing, measurement, and evaluation purposes. The client understands that certain tests may damage or destroy the sample and acknowledge that Vista Labs is not responsible for such damages. Samples will be returned only upon request by the applicant and at the applicant’s expense, after the completion of certification. Samples will be disposed of after six months if not requested for return by applicant. The product is ineligible for certification if it has been modified by the client after testing or certification. Changes to the product must be approved by Vista Laboratories. Vista Labs reserves the right to re- evaluate the product as a result of information that raises questions concerning the conformance of the product. Certified products maintain fulfilment of product requirements if the certification applies to ongoing production. If the client provides copies of the certification documents to other parties, the documents are reproduced in their entirety, or as specified in the certification scheme. In making reference to its product certification in media, such as brochures or advertisement, the client complies with the requirements of the Vista Labs or as specified by the certification scheme. The client complies with any requirements that may be prescribed in the certification scheme relating to the use of marks of conformity, and on all product correspondences and product related information. Vista Labs reserves the right to revise or withdraw the requirements as required in order to maintain conformance with FCC rules and regulations governing the product. The product may continue with certification and receive certification upon demonstration of compliance with the revised requirements, to the satisfaction of Vista Laboratories.

  • Information Requirement The successful bidder's shall be required to advise the Office of Management and Budget, Government Support Services of the gross amount of purchases made as a result of the contract.

  • Submission Requirements Requirement Deliverable (Report Name) Due Date Submission System

  • Documentation Requirements ODM shall pay the MCP after it receives sufficient documentation, as determined by ODM, detailing the MCP’s Ohio Medicaid-specific liability for the Annual Fee. The MCP shall provide documentation that includes the following: 1. Total premiums reported on IRS Form 8963;

  • Information Requirements The Company covenants that, if at any time before the end of the Effectiveness Period the Company is not subject to the reporting requirements of the Exchange Act, it will cooperate with any Holder and take such further reasonable action as any Holder may reasonably request in writing (including, without limitation, making such reasonable representations as any such Holder may reasonably request), all to the extent required from time to time to enable such Holder to sell Registrable Securities without registration under the Securities Act within the limitation of the exemptions provided by Rule 144 and Rule 144A under the Securities Act and customarily taken in connection with sales pursuant to such exemptions. Upon the written request of any Holder, the Company shall deliver to such Holder a written statement as to whether it has complied with such filing requirements, unless such a statement has been included in the Company’s most recent report filed pursuant to Section 13 or Section 15(d) of Exchange Act. Notwithstanding the foregoing, nothing in this Section 7 shall be deemed to require the Company to register any of its securities (other than the Common Stock) under any section of the Exchange Act.

  • GRADUATION REQUIREMENTS I understand that in order to graduate from the program and to receive a certificate of completion, diploma or degree I must successfully complete the required number of scheduled clock hours as specified in the catalog and on the Enrollment Agreement, pass all written and practical examinations with a minimum score of 80%, and complete all required clinical hours and satisfy all financial obligations to the College.

  • Affirmative Action Requirements The State intends to carry out its responsibility for requiring affirmative action by its contractors.