Common use of Prior Authorization Requirement Clause in Contracts

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.

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 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 emergency in-patient treatment, and within 24 hours after the Emergency emergency ends and your condition stabilizes.

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. 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 services; • Contraception services that are not subject to any Cost Sharing Sharing; or • Obstetrical or gynecological ultrasound 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.

Prior Authorization Requirement. Certain types of care require Prior Authorization by us. This means that you or your Provider 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. xxxxx://xxxxxxxxx.xxx.xxx/PEL/DisplayDocument?ContentID=pel_00052739 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 services; • Contraception services that are not subject to any Cost Sharing Obstetrical Sharing; or • An obstetrical or gynecological ultrasound ultrasound. However, we require authorization Prior Authorization for continued inIn-patient care if you are admitted to a Hospital hospital for Emergency emergency treatment, but your condition is stabilized. You or your Provider must notify us as soon as possible from when you begin receiving Emergency inemergency In-patient treatment, and within 24 hours after the Emergency emergency ends and your condition stabilizes.