Prior Authorization Review. Health Plan shall timely respond to requests for prior authorization and/or determination of Covered Services.
Prior Authorization Review. Initial Adverse Determination If we do not approve the Prior Authorization request (Adverse Determination) we will notify you and your Practitioner/Provider by phone (or as required by your medical situation) within 24 hours of making our decision. We will also notify you and your Practitioner/Provider of the Adverse Determination by written or electronic communication sent within one working day of a phone notice. Our notice will include: • Reasons for a Medical Necessity denial including why the requested healthcare service is not Medically Necessary. • The reason for a denial based on lack of coverage and a reference to all healthcare plan provisions on which the denial is based and a clear and complete explanation of why the Healthcare Service is not Covered. • An explanation of how you may request our internal review of our Adverse Determination including any forms that must be used and completed. Please see the Complaints, Grievances and Appeals Section for information regarding how to request an internal review of any Adverse Determinations that we make.
Prior Authorization Review. Health Plan will respond with a determination on a prior authorization request in accordance with the time frames required by Laws and Government Program Requirements after receiving all necessary information from Provider.
