Prior Authorizations. All prior authorization reviews and communications will be conducted in compliance with all applicable state and federal laws, the State Contract and applicable attachments. Subcontractor or Health Plan (as applicable) will establish a process that will allow Provider to submit and receive determination via a secure electronic transmission.
Prior Authorizations. The Department shall provide a common Prior Authorization Form for all Contractors to utilize for a Provider to initiate the prior authorization process. The Contractor shall give the Provider the option to use the common form or the Contractor specific form. The Contractor’s prior authorization process shall comply with 907 KAR 17:025 Section 2.
Prior Authorizations. Prior authorization(s) from COUNTY, which specifies the number of CLIENT contacts during a specified authorization period is required. COUNTY shall not be obligated to compensate CONTRACTOR for services rendered during a non-authorized period, for services provided in excess of an authorized period, or services in excess of number of authorized services, pursuant to the terms and conditions of this Agreement, and as described in the Network Provider Manual, prior to the time services are rendered.
Prior Authorizations. Prior authorization(s) from COUNTY shall be required for all non-routine mental health services.
Prior Authorizations. At any point that the Agency redistributes membership within the IA Health Link program or following open enrollment, the Contractor shall honor existing authorizations for covered Benefits for a minimum of 90 Days, without regard to whether such services are being provided by contract or non-contract Providers, when an Enrolled Member transitions to the Contractor from another source of coverage. LTSS, residential services and certain services rendered to dual diagnosis populations, which are addressed in F.13.28, are excluded from this 90-Day period. The Contractor shall honor existing exceptions to policy granted by the Director for the scope and duration designated. At all other times outside of Agency member redistribution and following open enrollment, the Contractor shall honor existing authorizations for a minimum of 30 Days when an Enrolled Member transitions to the Contractor from another source of coverage, without regard to whether services are being provided by contract or non-contract Providers. The Contractor shall obtain Agency approval for policies and procedures to identify existing Prior Authorizations at the time of enrollment. The Contractor shall implement and adhere to the Agency-approved policies and procedures. Additionally, when an Enrolled Member transitions to another Program Contractor, the Contractor shall provide the receiving entity with information on any current service authorizations, utilization data and other applicable clinical information such as disease management or Care Coordination notes.
Prior Authorizations. The CONTRACTOR must also offer an integrated prior authorization process that provides PARTICIPANTS with a consolidated medical and benefit (such as deductible, coinsurance and copayment) determination. Prior authorizations with out-of-pocket cost sharing information, including the possibility of BALANCE BILLING if applicable, must be provided to PARTICIPANTS in writing. In urgent situations, prior authorizations may be provided verbally, as long as the PARTICIPANT is notified of cost sharing responsibilities, and it is documented in the PARTICIPANT’S records/file. The CONTRACTOR must still follow up with a written notice. This provision also applies when a provider is seeking the prior authorization on the PARTICIPANT’S behalf. If the cost sharing is not disclosed at the time of prior authorization, the CONTRACTOR shall hold the PARTICIPANT harmless for out-of-pocket amounts above that of an equivalent IN-NETWORK service, and shall not charge this difference to the DEPARTMENT. The CONTRACTOR shall work with the DEPARTMENT to develop strategies for OUT-OF- NETWORK costs, including, but not limited to, the use of PARTICIPANT incentives, prior authorization, and negotiating provider fees. The CONTRACTOR shall be responsible for the full cost of any services not covered under the CONTRACT for which the CONTRACTOR provides written prior authorization to the PARTICIPANT and/or provider for the non-covered service. 215B Department Initiatives The CONTRACTOR is required to implement and report on the DEPARTMENT Initiatives. DEPARTMENT Initiatives are subject to change, as determined by the DEPARTMENT, to better serve the needs of the HEALTH BENEFIT PROGRAM PARTICIPANTS. The CONTRACTOR may coordinate with HOSPITALS, provider groups, or vendors to ensure the requirements of the DEPARTMENT Initiatives are met. The current DEPARTMENT Initiatives are:
Prior Authorizations. Purchases and Cash Advances may require our prior authorization. We may limit the number of authorizations we will give your Account on any one day. In the event that our authorization system is not fully operational, we may not be able to give our approval for transactions even though they would not exceed your Credit Xxxxx.Xxx agree that neither we nor our authorization agent shall be liable for not giving an authorization in such case.
Prior Authorizations. Certain Prescription Drug Benefits require prior approval before they will be covered by a Payer. Such approval is Plan specific. Follow the guidelines on the Plan Profile Sheet for directions on obtaining the requisite prior approval.
Prior Authorizations. Pharmacy Benefit Manager will, as required by State, confirm with Practitioners whether certain Covered Products are prescribed for medical conditions consistent with FDA-approved indications and labeling, or are appropriate for the diagnosis in the judgment of the Practitioner. In providing any or all such services, Pharmacy Benefit Manager may rely upon information provided by the Member or such person’s representative, the Practitioner, the dispensing pharmacist and other sources deemed reliable by Pharmacy Benefit Manager. Pharmacy Benefit Manager will not determine medical necessity or appropriateness of treatment, although Pharmacy Benefit Manager may rely upon protocols established and maintained by its Pharmacy and Therapeutics Committee (consisting of pharmacists and physicians) based upon factors such as safety, availability, potential for misuse and cost in its review of Claims submitted for payment of such prescription drugs. The Pharmacy Benefit Manager’s standard prior authorization list will be made available to State along with any Pharmacy Benefit Manager approved criteria for use. The Pharmacy Benefit Manager will communicate any changes to the prior authorization list in advance to State. Drug prior authorizations will be submitted and accessible by Practitioners and accepted by the Pharmacy Benefit Manager and the Employee Plan, electronically through secure electronic submissions consistent with all applicable laws. Facsimile does not constitute electronic transmissions. State acknowledges that Pharmacy Benefit Manager may suspend processing of Claims for Covered Products subject to prior authorization in the event the Practitioner fails to provide missing information necessary for the processing of such Claims in compliance with such protocols.
Prior Authorizations. Except with respect to Emergency services, Provider shall obtain prior authorization for the provision of certain Covered Services, as applicable, in accordance with Saint Marys’ policies and procedures as set forth in the Provider Manual.
