Service Authorization. 9.1. CONTRACTOR will collaborate with COUNTY to complete authorization requests in line with COUNTY and DHCS policy.
Service Authorization. Provider shall comply with the Authorization procedures and requirements set forth in the Provider Manual and this Section 2.3. Provider understands and agrees that, except in the case of Emergency Services, Medically Necessary post- stabilization care services deemed Authorized pursuant to Section 1300.71.4(b)(2) of Title 28 of the California Code of Regulations, or as otherwise provided in the Provider Manual, Provider Services must be Authorized in advance by Blue Shield or its delegate in order for Provider to be eligible for payment hereunder. Blue Shield will not retroactively deny Provider’s claims on the basis of Medical Necessity for services reviewed and Authorized pursuant to the Quality Improvement and Utilization Management Program, provided that Provider submitted full and accurate information to Blue Shield for review under its Quality Improvement and Utilization Management Program. If Provider fails to obtain Authorization prior to providing Provider Services to a Member, as required, or if Provider provides services outside of the scope of the Authorization obtained, then Blue Shield, or its delegate, shall have no obligation to compensate Provider for such services; Provider will be deemed to have waived payment for such services and shall not seek payment from Blue Shield, its delegate, or the Member.
Service Authorization. CalOptima shall provide a written authorization process for County Services pursuant to CalOptima Policies.
Service Authorization. A. Contractor shall implement mechanisms to assure authorization decision standards are met. The Contractor shall:
1) Have in place, and follow, written policies and procedures for processing requests for initial and continuing authorizations of services. (42 C.F.R. § 438.210(b)(1).)
2) Have mechanisms in effect to ensure consistent application of review criteria for authorization decisions, and shall consult with the requesting provider when appropriate. (42 C.F.R. § 438.210(b)(2)(i- ii).)
3) Have any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by a health care professional who has appropriate clinical expertise in addressing the beneficiary’s behavioral health needs. (42 C.F.R. § 438.210(b)(3).)
4) Notify the requesting provider, and give the beneficiary written notice of any decision by the Contractor to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. (42 C.F.R. § 438.210(c)) The beneficiary’s notice shall meet the requirements in Attachment 12, Section 10, paragraph A and Section 9, paragraph I and be provided within the timeframes set forth in Attachment 12, Section 10, paragraph B and Section 9, paragraph I.
B. For standard authorization decisions, the Contractor shall provide notice as expeditiously as the beneficiary’s condition requires not to exceed 14 calendar days following receipt of the request for service, with a possible extension of up to 14 additional calendar days when:
1) The beneficiary, or the provider, requests extension; or
2) The Contractor justifies (to the Department upon request) a need for additional information and how the extension is in the beneficiary’s interest. (42 C.F.R. § 438.210(d)(1))
C. For cases in which a provider indicates, or the Contractor determines, that following the standard timeframe could seriously jeopardize the beneficiary’s life or health or ability to attain, maintain, or regain maximum function, the Contractor shall make an expedited authorization decision and provide notice as expeditiously as the beneficiary’s health condition requires and no later than 72 hours after receipt of the request for service. The Contractor may extend the 72-hour time period by up to 14 calendar days if the beneficiary requests an extension, or if the Contractor justifies (to the Department upon request) a need for additional information and how t...
Service Authorization. 19.1 Contractor will collaborate with County to complete authorization requests in line with County and DHCS policy and Contract Exhibit A. [BHRS-77: Substance Use Residential Authorization]
19.2 Contractor shall respond to County within 24 hours when consultation is necessary for County to make appropriate authorization determinations.
19.3 County shall provide Contractor with written notice of authorization determinations within the timeframes set forth in BHIN 24-001, or any subsequent DHCS notices.
19.4 For SUD Non-Residential and Non-Inpatient Levels of Care service authorization:
19.4.1 Contractor shall follow County’s policies and procedures around non-residential/non- inpatient levels of care according to BHIN 24-001.
19.4.2 Contractor is not required to obtain service authorization for non-residential/non-inpatient levels of care. Prior authorization is prohibited for non-residential DMC-ODS services.
19.5 For SUD Residential and Inpatient Levels of Care service authorization:
19.5.1 Contractor shall have in place, and follow, County written authorization policies and procedures for processing requests for initial and continuing authorization, or prior authorization, for residential treatment services, including inpatient services, but excluding withdrawal management services.
19.6.2 County will review the DSM and ASAM Criteria to ensure that the beneficiary meets the requirements for the service.
19.6.3 Prior authorization for residential and inpatient services (excluding withdrawal management services) shall be made within 24 hours of the prior authorization request being submitted by the provider.
19.6.3.1 County will ensure that prior authorization processes are completed in a manner that assures the provision of a covered SUD service to a client in a timely manner appropriate for the client’s condition.
19.6.4 Contractor shall alert County when an expediated service authorization decision is necessary due to a client’s specific needs and circumstances that could seriously jeopardize the client’s life or health, or ability to attain, maintain, or regain maximum function. Expediated service authorizations shall not exceed 72 hours after receipt of the request for service, with a possible extension of up to 14 calendar days if the client or provider requests an extension.
19.6.5 Contractor shall alert County when a standard authorization decision is necessary. Standard service authorizations shall not exceed 14 calendar days following receipt of...
Service Authorization. A. The Contractor may not require prior authorization for Physician, Chiropractor, CRNP, and Respiratory Care services but may require that these services require a referral from the Participant's PCP. The Contractor shall prior authorize all other Capitation Services, in accordance with the practice guidelines for authorization decisions developed as specified in Section 2.1.Z and the procedures in this Section.
B. The Contractor must develop written policies and procedures for timely resolution of requests submitted on behalf of a Participant to initiate, terminate, reduce, or continue a service, including the role of the PCP and Team, consistent application of the practice guidelines for authorization decisions developed as specified in Section 2.1.Z, and consultation with the requesting Provider when appropriate.
C. Any decision to deny a request for a service or to authorize a service in an amount, duration, or scope that is less than requested must be made by a health care professional who has the appropriate clinical expertise in treating the Participant's condition or disease and who was not involved and does not supervise a person involved in the development of the Participant's ISP, including the Crisis Intervention Plan and Behavioral Support Plan if applicable.
D. The Contractor may not structure compensation to individuals who review requests for services in a manner that provides incentives for the individual to deny, limit, or discontinue Medically Necessary services to a Participant.
E. Each Authorized Service must be the least-restrictive, most- inclusive, and cost-effective feasible option that meets the Participant's needs.
F. Services may be denied or authorized in an amount, duration, or scope less than requested only on the basis of lack of medical necessity or inconsistency with accepted medical and behavioral health practices and professional standards.
G. The amount, duration, or scope of a service may not be arbitrarily denied, reduced, or terminated solely because of the diagnosis, illness, or condition of a Participant.
H. Any request to authorize care in a Nursing Facility or ICF setting must be submitted to BSASP for review prior to authorization on the form provided by BSASP and include the ISP. The review by BSASP will be within the time frames for authorization specified in this Section.
I. If the Contractor determines that a Participant needs Residential Habilitation Services, the Contractor prior to authorizing the servic...
Service Authorization. A. Contractor shall implement mechanisms to assure authorization decision standards are met in accordance with Mental Health and Substance Use Disorder Services (MHSUDS) Information Notice 19-026, or any subsequent Departmental notices issued to address parity in mental health and substance use disorder benefits subsequent to the effective date of this contract, and any applicable state and federal regulations. (42 C.F.R. § 438.910(d).) The Contractor shall:
1) Have in place, and follow, written policies and procedures for processing requests for initial and continuing authorizations of services. (42 C.F.R. § 438.210(b)(1).)
2) Have mechanisms in effect to ensure consistent application of review criteria for authorization decisions, and shall consult with the requesting provider when appropriate. (42 C.F.R. § 438.210(b)(2)(i- ii).)
3) Have any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by a health care professional who has appropriate clinical expertise in addressing the beneficiary’s behavioral health needs. (42 C.F.R. § 438.210(b)(3).)
4) Notify the requesting provider and give the beneficiary written notice of any decision by the Contractor to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. (42 C.F.R. § 438.210(c)) The beneficiary’s notice shall meet the requirements in Attachment 12, Section 10, paragraph A and Section 9, paragraph I and be provided within the timeframes set forth in Attachment 12, Section 10, paragraph B and Section 9, paragraph I G.
B. For standard authorization decisions, the Contractor shall provide notice as expeditiously as the beneficiary’s condition requires not to exceed 14 calendar days following receipt of the request for service, with a possible extension of up to 14 additional calendar days when:
1) The beneficiary, or the provider, requests extension; or
2) The Contractor justifies (to the Department upon request) a need for additional information and how the extension is in the beneficiary’s interest. (42 C.F.R. § 438.210(d)(1))
Service Authorization. 3.1.1. CONTRACTOR will collaborate with COUNTY to complete authorization requests in line with COUNTY and DHCS policy.
3.1.2. CONTRACTOR shall have in place, and follow, written policies and procedures for completing requests for initial and continuing authorizations of services, as required by COUNTY guidance.
3.1.3. CONTRACTOR shall respond to COUNTY in a timely manner when consultation is necessary for COUNTY to make appropriate authorization determinations.
3.1.4. COUNTY shall provide CONTRACTOR with written notice of authorization determinations within the timeframes set forth in BHINs 22-016 and 22-017, or any subsequent DHCS notices.
3.1.5. CONTRACTOR shall alert COUNTY when an expedited authorization decision (no later than 72 hours) is necessary due to a member’s specific needs and circumstances that could seriously jeopardize the member’s life or health, or ability to attain, maintain, or regain maximum function.
Service Authorization. CDDP must authorize Services as outlined below:
a. All Services, regardless of service setting or unless otherwise noted, must be authorized in eXPRS or MMIS for Long-Term Community Care Nursing (LTCCN), in a manner consistent with rule, by the CDDP in which the Individual is enrolled and is receiving Case Management Services and found eligible for I/DD Services as outlined in OAR Chapter 411, Division 320. This authorization must be obtained and documented in accordance with OARs and ODHS policies and procedures.
b. All Services must be authorized at the appropriate rate for the service setting. All Services included in the expenditure guidelines must be entered using the rates detailed in the expenditure guidelines. Rates are subject to change upon notice from ODHS.
Service Authorization. The Contractor may place limits on a service in accordance with federal regulations and requirements of this Contract as set forth in this section and Section 30.1 “
