Common use of Prior Authorization Clause in Contracts

Prior Authorization. This means a determination by our medical directors, or their designees, that an admission, extension of stay, or other health care service has been reviewed and that, based on the information provided, it satisfies our utilization review requirements. We will then pay for the covered benefit, provided the general exclusion provisions, and any deductible, copayment, coinsurance, or other policy requirements have been met. Reconstructive Surgery. This is limited to reconstructive surgery, incidental to or following surgery, resulting from injury or illness of the involved part, or to correct a congenital disease or anomaly resulting in functional defect in a dependent child, as determined by the attending physician.

Prior Authorization. This means a determination by our medical or dental directors, or their designees, that an admission, extension of stay, or other health care service has been reviewed and that, based on the information provided, it satisfies our utilization review requirements. We will then pay for the covered benefit, provided the general exclusion provisions, and any deductible, copayment, coinsurance, or other policy requirements have been met. Reconstructive Surgery. This is limited to reconstructive surgery, incidental to or following surgery, resulting from injury or illness of the involved part, or to correct a congenital disease or anomaly resulting in functional defect in a dependent child, as determined by the attending physician.