Common use of Prior Authorization Review – Initial Adverse Determination Clause in Contracts

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 within twenty-four (24) hours of making our decision. 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 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 mplaintsComplaints, 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 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 mplaintsComplaints, 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 within twenty-four (24) hours of making our decision. 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 health care healthcare service is not Medically Necessary.  • The reason for a denial based on lack of coverage and a reference to all health care healthcare plan provisions on which the denial is based and a clear and complete explanation of why the Health Care 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 C mplaintsComplaints, Grievances and Appeals Section for information regarding how to request an internal review of any Adverse Determinations that we make. Presbyterian will not retroactively deny authorization if a provider relied upon a written prior authorization from Presbyterian, received prior to providing the benefit, except in those cases where there was material misrepresentation or fraud by the provider.

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) 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) 1 working day of a telephone notice. Our notice will include:  • Reasons for a Medical Necessity denial including why the requested health care healthcare service is not Medically Necessary.  • The reason for a denial based on lack of coverage and a reference to all health care healthcare plan provisions on which the denial is based and a clear and complete explanation of why the Health Care Healthcare Service is not Covered.  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 mplaintsComplaints, Grievances and Appeals Section for information regarding how to request an internal review of any Adverse Determinations that we make. Presbyterian will not retroactively deny authorization if a provider relied upon a written prior authorization from Presbyterian, received prior to providing the benefit, except in those cases where there was material misrepresentation or fraud by the provider.

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 within twenty-four (24) hours of making our decision. 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 health care healthcare service is not Medically Necessary.  • The reason for a denial based on lack of coverage and a reference to all health care healthcare plan provisions on which the denial is based and a clear and complete explanation of why the Health Care 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 C mplaintsComplaints, 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 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 mplaintsComplaints, 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 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 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 mplaintsComplaints, Grievances and Appeals Section for information regarding how to request an internal review of any Adverse Determinations that we make.