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 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. Benefits‌‌ This Health Care Benefit Plan offers Coverage for a wide range of Health Care Services. This Section gives you the details about your benefits, Prior Authorization and other requirements, Limitations and Exclusions. Specifically Covered 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 limitation 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 Health Care Service or supply does not guarantee that it is a Covered Benefit even if it is not listed as an Exclusion. Specifically Covered Benefits are subject to the Limitations, Exclusions, Prior Authorization and other provisions of this Agreement. Medical Necessity This Health Care Benefit Plan helps pay for healthcare expenses that are Medically Necessary and specifically Covered in this Agreement. Medical Necessity or Medically Necessary means Health Care Services determined by a Practitioner/Provider, in consultation with Presbyterian Insurance Company, Inc. (PIC), to be appropriate or necessary, according to any applicable generally accepted principles and practices of good medical care or practice guidelines developed by the federal government, national or professional medical societies, boards and associations, or any applicable clinical protocols or practice guidelines we developed consistent with such federal, national, and professional practice guidelines, for the diagnosis or direct care and treatment of a physical, behavioral or mental health condition, illness, injury, or disease.‌‌ Experimental or Investigational drugs, medicines, treatments, procedures, or devices are not Covered. This does not include Clinical Trials. Please refer to Clinical Trials in the Benefit Section of this Agreement. Care Coordination and Case Management Care Coordination and Case Management are provided by our Care Coordination Department which is staffed with registered nurses, social workers, health educators, behavioral health specialists and non-licensed care coordinators that coordinate Covered and non-Covered Health Care Services for you when you have ongoing or complex diagnoses. The role of the care coordinator/case manager is to support and educate you and other Members, so that you are able to make informed healthcare decisions. Our ongoing communication and visits to you and to other Members who may have a chronic illness can trigger prompt intervention and help in the prevention of avoidable episodes of illness. We are committed to the personal service that care management provides to you when you are in need. When you are in the Hospital, our care coordinators/case managers work with the Hospital, their discharge planners and your Practitioners to make sure you get the appropriate level of care and to coordinate your care after you leave the Hospital. Disease management lifestyle coaches work with you to help you better manage your chronic disease, such as diabetes, coronary artery disease or congestive heart failure. Care is focused on helping you identify goals and desires for improving management of your chronic disease. PresRN Presbyterian Insurance Company members have access to PresRN, a nurse advice line available 24 hours a day, seven days a week, including holidays. PresRN is a no-cost service for Presbyterian Insurance Company Members. Please call at (000) 000-0000 or 0-000-000-0000. Health Management Programs Members have access to resources that support personal health management including online tools, print materials and programs or services to help enhance quality of life in three areas: staying healthy, preventing illness and living with a chronic condition. We help you reach optimum health through educational tools (such as those available on the myPRES Member Portal). Preventive Health Guidelines (such as Mammography and childhood immunizations) as well as with disease management for conditions such as asthma, depression and, diabetes. If you would like more information about these services visit xxxxx://xxx.xxx.xxx/tools-resources/member/Pages/default.aspx. Members can also call our Presbyterian Customer Service Center at (000) 000-0000 or‌‌‌ 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Covered Benefits Accidental Injury (Trauma), Urgent Care, Emergency Health Care Services, and Observation Services This benefit has one or more exclusions as specified in the Exclusions Section.

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 health care service is not Medically Necessary. • The reason for a denial based on lack of coverage and a reference to all healthcare 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. Benefits‌‌ This Health Care Benefit Plan offers Coverage for a wide range of Health Care Services. This Section gives you the details about your benefits, Prior Authorization and other requirements, Limitations and Exclusions. Specifically Covered This Health Care Benefit Plan helps pay for healthcare health care 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 Health Plan will not deny or limit coverage, deny or limit coverage of a claim, or impose additional cost-sharing or other limitation 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 Health Care Service or supply does not guarantee that it is a Covered Benefit even if it is not listed as an Exclusion. Specifically Covered Benefits are subject to the Limitations, Exclusions, Prior Authorization and other provisions of this Agreement. Medical Necessity This Health Care Benefit Plan helps pay for healthcare health care expenses that are Medically Necessary and specifically Covered in this Agreement. Clinical Preventive Health Services do not have to be “Medically Necessary”. Medical Necessity or Medically Necessary means Health Care Services determined by a Practitioner/Provider, in consultation with Presbyterian Insurance Company, Inc. Health Plan (PICPHP), to be appropriate or necessary, according to any applicable generally accepted principles and practices of good medical care or practice guidelines developed by the federal government, national or professional medical societies, boards and associations, or any applicable clinical protocols or practice guidelines we developed consistent with such federal, national, and professional practice guidelines, for the diagnosis or direct care and treatment of a physical, behavioral or mental health condition, illness, injury, or disease.‌‌ Experimental or Investigational drugs, medicines, treatments, procedures, or devices are not Covered. This does not include Clinical Trials. Please refer to Clinical Trials in the Benefit Section of this Agreement. Care Coordination and Case Management Care Case Coordination and Case Management are provided by our Care Coordination Department which is staffed with registered nurses, social workers, health educators, behavioral health specialists and non-licensed care coordinators that coordinate Covered and non-Covered Health Care Services for you when you have ongoing or complex diagnoses. The role of the care coordinator/case manager is to support and educate you and other Members, so that you are able to make informed healthcare health care decisions. Our ongoing communication and visits to you and to other Members who may have a chronic illness can trigger prompt intervention and help in the prevention of avoidable episodes of illness. We are committed to the personal service that care management provides to you when you are in need. When you are in the Hospital, our care coordinators/case managers work with the Hospital, their discharge planners and your Practitioners to make sure you get the appropriate level of care and to coordinate your care after you leave the Hospital. Disease management lifestyle coaches work with you to help you better manage your chronic disease, such as diabetes, coronary artery disease or congestive heart failure. Care is focused on helping you identify goals and desires for improving management of your chronic disease. PresRN Presbyterian Insurance Company Health Plan members have access to PresRN, a nurse advice line available 24 hours a day, seven (7) days a week, including holidays. PresRN is a no-cost service for Presbyterian Insurance Company Health Plan Members. Please call at (000) 000-0000 or 0-000-000-0000. Health Management Programs Members have access to resources that support personal health management including online tools, print materials and programs or services to help enhance quality of life in three areas: staying healthy, preventing illness and living with a chronic condition. We help you reach optimum health through educational tools (such as those available on the myPRES Member Portal). , Preventive Health Guidelines (such as Mammography and childhood immunizations) as well as with disease management for conditions such as asthma, depression and, and diabetes. If you would like more information about these services services, visit xxxxx://xxx.xxx.xxx/tools-resources/member/Pages/default.aspx. Members can also call our Presbyterian Customer Service Center at (000) 000-0000 or‌‌‌ 0-000-000-0000, Monday through Friday Friday, from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Covered Benefits Accidental Injury (Trauma), Urgent Care, Emergency Health Care Services, and Observation Services This benefit has one or more exclusions as specified in the Exclusions Section.

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 health care service is not Medically Necessary. • The reason for a denial based on lack of coverage and a reference to all healthcare 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. Benefits‌‌ This Health Care Benefit Plan offers Coverage for a wide range of Health Care Services. This Section gives you the details about your benefits, Prior Authorization and other requirements, Limitations and Exclusions. Specifically Covered This Health Care Benefit Plan helps pay for healthcare health care 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 Health Plan will not deny or limit coverage, deny or limit coverage of a claim, or impose additional cost-sharing or other limitation 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 form 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 Health Care Service or supply does not guarantee that it is a Covered Benefit even if it is not listed as an Exclusion. Specifically Covered Benefits are subject to the Limitations, Exclusions, Prior Authorization and other provisions of this Agreement. Medical Necessity This Health Care Benefit Plan helps pay for healthcare health care expenses that are Medically Necessary and specifically Covered in this Agreement. Clinical Preventive Health Services do not have to be “Medically Necessary”. Medical Necessity or Medically Necessary means Health Care Services determined by a Practitioner/Provider, in consultation with Presbyterian Insurance Company, Inc. Health Plan (PICPHP), to be appropriate or necessary, according to any applicable generally accepted principles and practices of good medical care or practice guidelines developed by the federal government, national or professional medical societies, boards and associations, or any applicable clinical protocols or practice guidelines we developed consistent with such federal, national, and professional practice guidelines, for the diagnosis or direct care and treatment of a physical, behavioral or mental health condition, illness, injury, or disease.‌‌ Experimental or Investigational drugs, medicines, treatments, procedures, or devices are not Covered. This does not include Clinical Trials. Please refer to Clinical Trials in the Benefit Section of this Agreement. Care Coordination and Case Management Care Case Coordination and Case Management are provided by our Care Coordination Department which is staffed with registered nurses, social workers, health educators, behavioral health specialists and non-licensed care coordinators that coordinate Covered and non-Covered Health Care Services for you when you have ongoing or complex diagnoses. The role of the care coordinator/case manager is to support and educate you and other Members, so that you are able to make informed healthcare health care decisions. Our ongoing communication and visits to you and to other Members who may have a chronic illness can trigger prompt intervention and help in the prevention of avoidable episodes of illness. We are committed to the personal service that care management provides to you when you are in need. When you are in the Hospital, our care coordinators/case managers work with the Hospital, their discharge planners and your Practitioners to make sure you get the appropriate level of care and to coordinate your care after you leave the Hospital. Disease management lifestyle coaches work with you to help you better manage your chronic disease, such as diabetes, coronary artery disease or congestive heart failure. Care is focused on helping you identify goals and desires for improving management of your chronic disease. PresRN Presbyterian Insurance Company Health Plan members have access to PresRN, a nurse advice line available 24 hours a day, seven (7) days a week, including holidays. PresRN is a no-cost service for Presbyterian Insurance Company Health Plan Members. Please call at (000) 000-0000 or 0-000-000-0000. Health Management Programs Members have access to resources that support personal health management including online tools, print materials and programs or services to help enhance quality of life in three areas: staying healthy, preventing illness and living with a chronic condition. We help you reach optimum health through educational tools (such as those available on the myPRES Member Portal). , Preventive Health Guidelines (such as Mammography and childhood immunizations) as well as with disease management for conditions such as asthma, depression and, and diabetes. If you would like more information about these services services, visit xxxxx://xxx.xxx.xxx/tools-resources/member/Pages/default.aspx. Members can also call our Presbyterian Customer Service Center at (000) 000-0000 or‌‌‌ 0-000-000-0000, 0000 Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Covered Benefits Accidental Injury (Trauma), Urgent Care, Emergency Health Care Services, and Observation Services This benefit has one or more exclusions as specified in the Exclusions Section.

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. Benefits‌‌ This Health Care Benefit Plan offers Coverage for a wide range of Health Care Services. This Section gives you the details about your benefits, Prior Authorization and other requirements, Limitations and Exclusions. Specifically Covered 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 limitation 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 Health Care Service or supply does not guarantee that it is a Covered Benefit even if it is not listed as an Exclusion. Specifically Covered Benefits are subject to the Limitations, Exclusions, Prior Authorization and other provisions of this Agreement. Medical Necessity This Health Care Benefit Plan helps pay for healthcare expenses that are Medically Necessary and specifically Covered in this Agreement. Medical Necessity or Medically Necessary means Health Care Services determined by a Practitioner/Provider, in consultation with Presbyterian Insurance Company, Inc. (PIC), to be appropriate or necessary, according to any applicable generally accepted principles and practices of good medical care or practice guidelines developed by the federal government, national or professional medical societies, boards and associations, or any applicable clinical protocols or practice guidelines we developed consistent with such federal, national, and professional practice guidelines, for the diagnosis or direct care and treatment of a physical, behavioral or mental health condition, illness, injury, or disease.‌‌ Experimental or Investigational drugs, medicines, treatments, procedures, or devices are not Covered. This does not include Clinical Trials. Please refer to Clinical Trials in the Benefit Section of this Agreement. Care Coordination and Case Management Care Coordination and Case Management are provided by our Care Coordination Department which is staffed with registered nurses, social workers, health educators, behavioral health specialists and non-licensed care coordinators that coordinate Covered and non-Covered Health Care Services for you when you have ongoing or complex diagnoses. The role of the care coordinator/case manager is to support and educate you and other Members, so that you are able to make informed healthcare decisions. Our ongoing communication and visits to you and to other Members who may have a chronic illness can trigger prompt intervention and help in the prevention of avoidable episodes of illness. We are committed to the personal service that care management provides to you when you are in need. When you are in the Hospital, our care coordinators/case managers work with the Hospital, their discharge planners and your Practitioners to make sure you get the appropriate level of care and to coordinate your care after you leave the Hospital. Disease management lifestyle coaches coaches’ work with you to help you better manage your chronic disease, such as diabetes, coronary artery disease or congestive heart failure. Care is focused on helping you identify goals and desires for improving management of your chronic disease. PresRN Presbyterian Insurance Company members Members have access to PresRN, a nurse advice line available 24 hours a day, seven days a week, including holidays. PresRN is a no-cost service for Presbyterian Insurance Company Members. Please call at (000) 000-0000 or 0-000-000-0000. Health Management Programs Members have access to resources that support personal health management including online tools, print materials and programs or services to help enhance quality of life in three areas: staying Staying healthy, preventing illness and living with a chronic condition. We help you reach optimum health through educational tools (such as those available on the myPRES Member Portal). Preventive Health Guidelines (such as Mammography and childhood immunizations) as well as with disease management for conditions such as asthma, depression and, diabetes. If you would like more information about these services visit xxxxx://xxx.xxx.xxx/tools-resources/member/Pages/default.aspx. Members can also call our Presbyterian Customer Service Center at (000) 000-0000 or‌‌‌ 0-000-000-0000, Monday through Friday from 7 a.m. to 6 p.m. Hearing impaired users may call TTY 711. Covered Benefits Accidental Injury (Trauma), Urgent Care, Emergency Health Care Services, and Observation Services This benefit has one or more exclusions as specified in the Exclusions Section.