{"component": "clause", "props": {"groups": [{"snippet_links": [{"key": "medical-directors", "type": "clause", "offset": [34, 51]}, {"key": "extension-of-stay", "type": "clause", "offset": [92, 109]}, {"key": "health-care-service", "type": "definition", "offset": [120, 139]}, {"key": "based-on", "type": "definition", "offset": [168, 176]}, {"key": "information-provided", "type": "clause", "offset": [181, 201]}, {"key": "utilization-review-requirements", "type": "clause", "offset": [220, 251]}, {"key": "pay-for", "type": "definition", "offset": [266, 273]}, {"key": "covered-benefit", "type": "definition", "offset": [278, 293]}, {"key": "general-exclusion", "type": "clause", "offset": [308, 325]}, {"key": "policy-requirements", "type": "clause", "offset": [391, 410]}, {"key": "reconstructive-surgery", "type": "definition", "offset": [426, 448]}, {"key": "incidental-to", "type": "definition", "offset": [493, 506]}, {"key": "resulting-from", "type": "definition", "offset": [529, 543]}, {"key": "illness-of", "type": "clause", "offset": [554, 564]}, {"key": "dependent-child", "type": "definition", "offset": [666, 681]}, {"key": "attending-physician", "type": "definition", "offset": [704, 723]}], "snippet": "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.", "samples": [{"hash": "kNKffmlHOXY", "uri": "/contracts/kNKffmlHOXY#prior-authorization", "label": "Membership Contract", "score": 32.7953186035, "published": true}, {"hash": "3P0sBemXVWp", "uri": "/contracts/3P0sBemXVWp#prior-authorization", "label": "Membership Contract", "score": 32.7953186035, "published": true}, {"hash": "lSZXN5s1jxR", "uri": "/contracts/lSZXN5s1jxR#prior-authorization", "label": "Membership Contract", "score": 31.8153400421, "published": true}], "size": 9, "hash": "b44f39c00e9b98f3e17cbbca4900d3c0", "id": 4}, {"snippet_links": [{"key": "emergency-services", "type": "definition", "offset": [11, 29]}, {"key": "provider-manual", "type": "definition", "offset": [82, 97]}, {"key": "in-accordance-with", "type": "clause", "offset": [163, 181]}, {"key": "not-permitted", "type": "clause", "offset": [216, 229]}, {"key": "program-requirements", "type": "definition", "offset": [241, 261]}, {"key": "health-plan", "type": "clause", "offset": [263, 274]}, {"key": "payment-for-covered-services", "type": "clause", "offset": [284, 312]}, {"key": "requirements-for", "type": "clause", "offset": [358, 374]}], "snippet": "Except for Emergency Services or where prior authorization is not required by the Provider Manual, Providers shall obtain prior authorization for Covered Services in accordance with the Provider Manual. Except where not permitted by Laws or Program Requirements, Health Plan may deny payment for Covered Services where a Provider fails to meet Health Plan\u2019s requirements for prior authorization.", "samples": [{"hash": "hr8hlhjL1tO", "uri": "/contracts/hr8hlhjL1tO#prior-authorization", "label": "Participating Provider Agreement", "score": 30.2523021698, "published": true}, {"hash": "2RW1BZenkqA", "uri": "/contracts/2RW1BZenkqA#prior-authorization", "label": "Participating Provider Agreement", "score": 26.1704311371, "published": true}, {"hash": "cmg35fvr21w", "uri": "/contracts/cmg35fvr21w#prior-authorization", "label": "Participating Provider Agreement", "score": 25.7392196655, "published": true}], "size": 8, "hash": "b69a77df3a4781ea392584dcf436c4b8", "id": 10}, {"snippet_links": [{"key": "step-therapy", "type": "definition", "offset": [0, 12]}], "snippet": "Step Therapy (trial of a lower cost drug before a higher cost drug is covered).", "samples": [{"hash": "dV01ky6Isd", "uri": "/contracts/dV01ky6Isd#prior-authorization", "label": "Collective Bargaining Agreement", "score": 32.1602478027, "published": true}, {"hash": "1pOCst9JYhy", "uri": "/contracts/1pOCst9JYhy#prior-authorization", "label": "Collective Bargaining Agreement", "score": 32.1465606689, "published": true}, {"hash": "72YSpmja9M", "uri": "/contracts/72YSpmja9M#prior-authorization", "label": "Collective Bargaining Agreement", "score": 26.8425731659, "published": true}], "size": 8, "hash": "a27faf9d45b14c74e80e71ab6e5a98fd", "id": 7}, {"snippet_links": [{"key": "services-covered", "type": "clause", "offset": [63, 79]}, {"key": "provide-a", "type": "definition", "offset": [114, 123]}, {"key": "treatment-of", "type": "clause", "offset": [145, 157]}, {"key": "duration-and-scope", "type": "clause", "offset": [169, 187]}, {"key": "a-member", "type": "definition", "offset": [191, 199]}, {"key": "prior-to-the", "type": "clause", "offset": [200, 212]}, {"key": "the-service", "type": "clause", "offset": [243, 254]}], "snippet": "A determination to authorize a Provider\u2019s request, pursuant to services covered in the MississippiCAN Program, to provide a service or course of treatment of a specific duration and scope to a Member prior to the initiation or continuation of the service.", "samples": [{"hash": "gFgpcQhc5Uu", "uri": "/contracts/gFgpcQhc5Uu#prior-authorization", "label": "Contract Between the State of Mississippi Division of Medicaid and a Coordinated Care Organization (Cco)", "score": 28.6930179596, "published": true}, {"hash": "4YHG9k1CAOl", "uri": "/contracts/4YHG9k1CAOl#prior-authorization", "label": "Contract Between the State of Mississippi Division of Medicaid and a Coordinated Care Organization (Cco)", "score": 28.6930179596, "published": true}, {"hash": "lO5otVuIty2", "uri": "/contracts/lO5otVuIty2#prior-authorization", "label": "Contract Between the State of Mississippi Division of Medicaid and a Coordinated Care Organization (Cco)", "score": 28.4953937531, "published": true}], "size": 16, "hash": "83e1ed9c22689bcd8163a0911e37c650", "id": 1}, {"snippet_links": [{"key": "county-shall", "type": "clause", "offset": [0, 12]}, {"key": "to-contractor", "type": "definition", "offset": [21, 34]}, {"key": "authorization-form", "type": "definition", "offset": [136, 154]}, {"key": "basis-of", "type": "clause", "offset": [162, 170]}, {"key": "the-county", "type": "clause", "offset": [197, 207]}, {"key": "contract-liaison", "type": "clause", "offset": [208, 224]}, {"key": "consent-of-the", "type": "clause", "offset": [235, 249]}, {"key": "county-and-contractor", "type": "clause", "offset": [250, 271]}, {"key": "date-of-admission", "type": "definition", "offset": [355, 372]}], "snippet": "County shall provide to Contractor written prior authorization for each patient admitted. A patient may be admitted without a completed authorization form on the basis of verbal authorization from the county contract liaison by mutual consent of the County and Contractor, provided County supplies a completed authorization within three (3) days from the date of admission.", "samples": [{"hash": "koP4dhx5Hus", "uri": "/contracts/koP4dhx5Hus#prior-authorization", "label": "Contract for Services by Independent Contractor", "score": 34.355304718, "published": true}, {"hash": "5rYL01aVylg", "uri": "/contracts/5rYL01aVylg#prior-authorization", "label": "Contract for Services", "score": 33.568901062, "published": true}, {"hash": "1T577SAHf4P", "uri": "/contracts/1T577SAHf4P#prior-authorization", "label": "Contract for Services by Independent Contractor", "score": 33.5665664673, "published": true}], "size": 16, "hash": "0431b4ce1b2592b4e633849036842ad3", "id": 2}, {"snippet_links": [{"key": "ability-to", "type": "clause", "offset": [9, 19]}, {"key": "to-ensure", "type": "clause", "offset": [63, 72]}, {"key": "appropriate-use", "type": "definition", "offset": [73, 88]}, {"key": "provide-a", "type": "definition", "offset": [172, 181]}, {"key": "requests-for", "type": "clause", "offset": [194, 206]}, {"key": "hours-of", "type": "clause", "offset": [237, 245]}, {"key": "the-request", "type": "clause", "offset": [246, 257]}], "snippet": "Have the ability to require Prior Authorization on medications to ensure appropriate use and to encourage the use of preferred medications.\n4.2.21.3.1. The CONTRACTOR must provide a response to requests for Prior Authorization within 24 hours of the request.\n4.2.21.3.2. Per 42 U.S.C 1396r 8(d)(5)(B) and 42 CFR 438.3(s)", "samples": [{"hash": "l8TIMM3H75O", "uri": "/contracts/l8TIMM3H75O#prior-authorization", "label": "Contract for Medical Services", "score": 25.0602321625, "published": true}, {"hash": "35uqLloWXCW", "uri": "/contracts/35uqLloWXCW#prior-authorization", "label": "Contract for Medical Services", "score": 24.9835720062, "published": true}, {"hash": "dMTLX3WZZFl", "uri": "/contracts/dMTLX3WZZFl#prior-authorization", "label": "Contract for Medical Services", "score": 24.7180023193, "published": true}], "size": 11, "hash": "9ae3e3d1e790bb6db3a172f4a6d95b91", "id": 3}, {"snippet_links": [{"key": "prior-authorized", "type": "definition", "offset": [54, 70]}, {"key": "task-list", "type": "definition", "offset": [124, 133]}, {"key": "the-individual", "type": "clause", "offset": [193, 207]}, {"key": "individual-support-plan", "type": "definition", "offset": [226, 249]}, {"key": "service-level-agreement", "type": "clause", "offset": [266, 289]}, {"key": "provided-that", "type": "definition", "offset": [319, 332]}, {"key": "the-consumer", "type": "definition", "offset": [352, 364]}, {"key": "common-law-employer", "type": "definition", "offset": [365, 384]}, {"key": "authorization-for-services", "type": "clause", "offset": [407, 433]}, {"key": "plan-of-care", "type": "clause", "offset": [443, 455]}, {"key": "emergency-or-urgent-situation", "type": "definition", "offset": [542, 571]}, {"key": "local-office-hours", "type": "definition", "offset": [590, 608]}, {"key": "notify-the", "type": "clause", "offset": [627, 637]}, {"key": "case-manager", "type": "definition", "offset": [638, 650]}, {"key": "plan-coordinator", "type": "definition", "offset": [662, 678]}, {"key": "business-days", "type": "clause", "offset": [694, 707]}], "snippet": "\u200c\na) HCWs/PSWs may not be paid for hours that are not prior authorized. Prior authorization for APD is the SDS 4105, or the task list and voucher. Prior authorization for ODDS services is when the individual has an authorized Individual Support Plan (ISP), there is service level agreement describing the support to be provided that has been signed by the Consumer/common law Employer and PSW, and there is authorization for services in eXPRS Plan of Care. Prior authorization for OHA services is considered the voucher.\nb) In the case of an emergency or urgent situation that occurs after local office hours, the HCW/PSW must notify the case manager or service plan coordinator within two (2) business days.", "samples": [{"hash": "1nXWgu4SEEZ", "uri": "/contracts/1nXWgu4SEEZ#prior-authorization", "label": "Collective Bargaining Agreement", "score": 24.0161018372, "published": true}, {"hash": "et8bV6osN2g", "uri": "/contracts/et8bV6osN2g#prior-authorization", "label": "Collective Bargaining Agreement", "score": 20.0903491974, "published": true}, {"hash": "N85sEQZkA6", "uri": "/contracts/N85sEQZkA6#prior-authorization", "label": "Collective Bargaining Agreement", "score": 20.0903491974, "published": true}], "size": 9, "hash": "3bc48fb897709cc1d59ef07aaac8b870", "id": 5}, {"snippet_links": [{"key": "to-verify", "type": "definition", "offset": [51, 60]}, {"key": "blue-shield", "type": "definition", "offset": [66, 77]}, {"key": "proposed-services", "type": "definition", "offset": [113, 130]}, {"key": "medically-necessary", "type": "definition", "offset": [197, 216]}, {"key": "clinically-appropriate", "type": "definition", "offset": [250, 272]}, {"key": "prior-authorization-process", "type": "clause", "offset": [278, 305]}, {"key": "services-rendered", "type": "definition", "offset": [372, 389]}, {"key": "participating-providers", "type": "definition", "offset": [393, 416]}, {"key": "summary-of-benefits", "type": "clause", "offset": [458, 477]}, {"key": "requests-for", "type": "clause", "offset": [511, 523]}, {"key": "receipt-of", "type": "clause", "offset": [575, 585]}, {"key": "the-request", "type": "clause", "offset": [586, 597]}, {"key": "treating-provider", "type": "definition", "offset": [603, 620]}, {"key": "the-decision", "type": "clause", "offset": [641, 653]}, {"key": "written-notice", "type": "clause", "offset": [674, 688]}, {"key": "to-the-member", "type": "clause", "offset": [702, 715]}, {"key": "business-days-of", "type": "clause", "offset": [740, 756]}, {"key": "urgent-services", "type": "clause", "offset": [775, 790]}, {"key": "decision-making-process", "type": "clause", "offset": [808, 831]}, {"key": "a-member", "type": "definition", "offset": [881, 889]}, {"key": "severe-pain", "type": "definition", "offset": [925, 936]}, {"key": "as-soon-as-possible", "type": "definition", "offset": [966, 985]}, {"key": "not-to-exceed", "type": "definition", "offset": [1025, 1038]}, {"key": "outpatient-prescription-drug-benefits", "type": "clause", "offset": [1086, 1123]}, {"key": "specific-information", "type": "clause", "offset": [1136, 1156]}, {"key": "prior-authorization-for-outpatient-prescription-drugs", "type": "clause", "offset": [1163, 1216]}, {"key": "services-provided", "type": "definition", "offset": [1264, 1281]}, {"key": "the-plan", "type": "clause", "offset": [1334, 1342]}, {"key": "radiological-and-nuclear-imaging", "type": "clause", "offset": [1437, 1469]}, {"key": "within-california", "type": "clause", "offset": [1632, 1649]}, {"key": "emergency-basis", "type": "definition", "offset": [1672, 1687]}], "snippet": "Prior authorization allows the Member and provider to verify with Blue Shield or Blue Shield\u2019s MHSA that (1) the proposed services are a Benefit of the Member\u2019s plan, (2) the proposed services are Medically Necessary, and (3) the proposed setting is clinically appropriate. The prior authorization process also informs the Member and provider when Benefits are limited to services rendered by Participating Providers or MHSA Participating Providers (See the Summary of Benefits). A decision will be made on all requests for prior authorization within five business days from receipt of the request. The treating provider will be notified of the decision within 24 hours and written notice will be sent to the Member and provider within two business days of the decision. For urgent services when the routine decision making process might seriously jeopardize the life or health of a Member or when the Member is experiencing severe pain, a decision will be rendered as soon as possible to accommodate the Member\u2019s condition, not to exceed 72 hours from receipt of the request. (See the Outpatient Prescription Drug Benefits section for specific information about prior authorization for outpatient prescription drugs). If prior authorization was not obtained, and services provided to the Member are determined not to be a Benefit of the plan or were not medically necessary, coverage will be denied. Prior authorization is required for radiological and nuclear imaging procedures. The Member or provider should call \u2587-\u2587\u2587\u2587-\u2587\u2587\u2587-\u2587\u2587\u2587\u2587 for prior authorization of the following radiological and nuclear imaging procedures when performed within California on an outpatient, non-emergency basis:", "samples": [{"hash": "gUlyGmEfHZM", "uri": "/contracts/gUlyGmEfHZM#prior-authorization", "label": "Blue Shield Gold 80 Ppo Ai an Plan Agreement", "score": 24.1594791412, "published": true}, {"hash": "f2D88iFNo0G", "uri": "/contracts/f2D88iFNo0G#prior-authorization", "label": "Blue Shield Minimum Coverage Ppo Plan Agreement", "score": 24.1594791412, "published": true}, {"hash": "3wsZ4pw2IkU", "uri": "/contracts/3wsZ4pw2IkU#prior-authorization", "label": "Blue Shield Minimum Coverage Ppo Plan Agreement", "score": 24.1594791412, "published": true}], "size": 9, "hash": "6582b76d73986e7f4343eedfe9da0b26", "id": 6}, {"snippet_links": [{"key": "prescription-drugs", "type": "definition", "offset": [8, 26]}, {"key": "for-information", "type": "clause", "offset": [121, 136]}, {"key": "phone-number", "type": "definition", "offset": [162, 174]}, {"key": "inside-front-cover", "type": "clause", "offset": [189, 207]}, {"key": "this-contract", "type": "definition", "offset": [211, 224]}, {"key": "not-limited", "type": "clause", "offset": [272, 283]}], "snippet": "Certain prescription drugs may require prior authorization before you can have your prescription filled at the pharmacy. For information, you may call PIC at the phone number listed on the inside front cover of this contract. These prescription drugs may include, but are not limited to:", "samples": [{"hash": "kCNSnk2fGwI", "uri": "/contracts/kCNSnk2fGwI#prior-authorization", "label": "Health Insurance Contract", "score": 25.9199180603, "published": true}, {"hash": "jWM4B6eq0tZ", "uri": "/contracts/jWM4B6eq0tZ#prior-authorization", "label": "Health Insurance Contract", "score": 25.9199180603, "published": true}, {"hash": "gAqySG9pCTf", "uri": "/contracts/gAqySG9pCTf#prior-authorization", "label": "Health Insurance Contract", "score": 23.9192333221, "published": true}], "size": 8, "hash": "0cab44a8a59b63f8bcc12a10e52058ae", "id": 8}, {"snippet_links": [{"key": "appropriate-use", "type": "definition", "offset": [55, 70]}, {"key": "prescription-drugs", "type": "definition", "offset": [84, 102]}, {"key": "the-risk", "type": "definition", "offset": [218, 226]}, {"key": "side-effects", "type": "clause", "offset": [249, 261]}, {"key": "the-process", "type": "clause", "offset": [287, 298]}, {"key": "for-managing", "type": "clause", "offset": [299, 311]}], "snippet": "Prior Authorization is a process that helps ensure the appropriate use of Specialty prescription drugs. This program is designed to promote a step wise approach of treatment (use of Drug A before using Drug B), manage the risk of drugs with serious side effects and positively influence the process for managing drug costs.", "samples": [{"hash": "9CReXzX8IK0", "uri": "/contracts/9CReXzX8IK0#prior-authorization", "label": "Collective Bargaining Agreement", "score": 27.1501598358, "published": true}, {"hash": "94gHBc8r7u9", "uri": "/contracts/94gHBc8r7u9#prior-authorization", "label": "Collective Bargaining Agreement", "score": 27.0560722351, "published": true}, {"hash": "eQzTnGlK3xQ", "uri": "/contracts/eQzTnGlK3xQ#prior-authorization", "label": "Collective Bargaining Agreement", "score": 26.9082756042, "published": true}], "size": 8, "hash": "4e8f75741aa9027210293e184abf5ab8", "id": 9}], "next_curs": "ClwSVmoVc35sYXdpbnNpZGVyY29udHJhY3RzcjgLEhZDbGF1c2VTbmlwcGV0R3JvdXBfdjU2Ihxwcmlvci1hdXRob3JpemF0aW9uIzAwMDAwMDBhDKIBAmVuGAAgAA==", "clause": {"title": "Prior Authorization", "size": 367, "parents": [["definitions", "DEFINITIONS"], ["core-benefits-and-services", "CORE BENEFITS AND SERVICES"], ["employer-not-responsible-for-grievance-time", "Employer Not Responsible For Grievance Time"], ["provider-responsibilities", "Provider Responsibilities"], ["grievance-procedure", "Grievance Procedure"]], "children": [["notice-of-action", "Notice of Action"], ["billing-for-services", "Billing for Services"], ["other-group-participating-providers", "Other Group Participating Providers"], ["adverse-determinations", "Adverse Determinations"], ["continued-extended-services", "Continued/Extended Services"]], "id": "prior-authorization", "related": [["power-authorization", "Power; Authorization", "Power; Authorization"], ["work-authorizations", "WORK AUTHORIZATIONS", "WORK AUTHORIZATIONS"], ["work-authorization", "Work Authorization", "Work Authorization"], ["required-authorizations", "Required Authorizations", "Required Authorizations"], ["legal-authorization", "LEGAL AUTHORIZATION", "LEGAL AUTHORIZATION"]], "related_snippets": [], "updated": "2025-07-24T04:27:57+00:00", "also_ask": ["What negotiation leverage does a prior authorization requirement provide to each party?", "Which essential elements must be included to ensure a prior authorization clause is enforceable?", "What are the most common pitfalls or ambiguities that undermine prior authorization provisions?", "How do prior authorization clauses differ across jurisdictions or industry standards?", "What evidence is typically required in court to prove compliance or breach of a prior authorization clause?"], "drafting_tip": "Specify required actions for obtaining prior authorization to ensure clarity; define exceptions to prevent disputes; state consequences for non-compliance to promote enforceability.", "explanation": "The Prior Authorization clause requires that one party obtain approval from the other party before taking certain actions or incurring specific expenses. In practice, this means that activities such as making significant purchases, entering into contracts, or initiating projects must be reviewed and explicitly permitted in advance. This clause helps ensure oversight and control, preventing unauthorized commitments and reducing the risk of disputes over unapproved actions."}, "json": true, "cursor": ""}}