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 telephone (or within twenty-four (24) hours of making our decision. as required by your medical situation) We will also notify you and your Practitioner/Provider of the Adverse Determination by written or electronic communication sent within one (1) working day of a telephone notice. Our notice will include: Reasons for a Medical Necessity denial including why the requested health care service is not Medically Necessary. The reason for a denial based on lack of coverage and a reference to all health care plan provisions on which the denial is based and a clear and complete explanation of why the Health Care 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 C mplaints, Grievances and Appeals Section for information regarding how to request an internal review of any Adverse Determinations that we make.
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 telephone (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 (1) working day of a telephone 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 Health Care 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. This Health Care Benefit Plan helps pay for healthcare expenses that are Medically Necessary and Specifically Covered in this Agreement. Specifically Covered means only those Health Care Benefits that are expressly listed and described in the Benefits Section of the Agreement. In addition, you should refer to the Exclusions Section that lists services that are not Covered under your Health Care Benefit Plan. All other benefits and services not specifically listed as Covered in the Benefits Section shall be excluded, except for Clinical Preventive Health Services and except as required by state or federal law. There are no annual or lifetime limits on the dollar value of essential health benefits, as defined under the Affordable Care Act. Presbyterian Insurance Company will not deny or limit coverage, deny or limit coverage of a claim, or impose additional cost-sharing or other limitations or restrictions on coverage, for any health services that are ordinarily or exclusively available to individuals of one sex, to a transgender individual based on the fact that an individual’s sex assigned at birth, gender identity, or gender otherwise recorded is different from the one to which such health services are ordinarily or exclusively available. We determine whether a Health Care Service or supply is a specifically Covered Benefit. The fact that a Practitioner/Provider has prescribed, ordered, recommended, or approved a H...
