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 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 Complaints, 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 ComplaintsC mplaints, Grievances and Appeals Section for information regarding how Refer to 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 ComplaintsC mplaints, Grievances and Appeals Section for information regarding how Refer to 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 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 Complaints, 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 twenty-four (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. Refer to 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 – 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 twenty-four (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. Refer to 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 – 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 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. Refer to Please see the Complaints, Grievances and Appeals Section for information regarding how to request an internal review of any Adverse Determinations that we make.