Common use of Service Authorization Policies and Procedures Clause in Contracts

Service Authorization Policies and Procedures. Services in the Long-Term Care Benefit Package The MCO may use the Resource Allocation Decision Method (RAD) as its service authorization policy. If the MCO does not use the RAD, it must seek Department approval of alternative service authorization policies and procedures. The policies and procedures must address how new and continuing authorizations of services are approved and denied. The MCO may choose to create decision-making guidelines for more frequently used items and/or services. When the MCO wishes to utilize these guidelines as part of the RAD or alternative service authorization documentation (instead of documenting evidence), the guidelines must be approved by the Department. Services shall be authorized in a manner that reflects the member’s ongoing need for such services and supports as determined through the comprehensive assessment and consistent with the member-centered plan. Acute and Primary Care Services in the Partnership Benefit Package The MCO shall have documented and Department-approved service authorization policies and procedures for services in the acute and primary care benefit package. Policies and procedures may differ from the authorization policies and procedures for services in the long-term care benefit package, and may be based on accepted clinical practices. Decisions about the authorization of services in the acute and primary care benefit package may be made outside of the IDT by other clinical professionals with consideration for member preferences. Authorization of Services in Partnership Dual Eligibles SNPs The MCO shall coordinate and authorize the delivery of covered Medicare, Medicaid, and long-term care services using aligned care management by first using Medicare coverage and authorization policies, procedures and requirements. If the MCO determines that Medicare will not cover the service, the MCO must then use and follow the Medicaid coverage rules, including the RAD, to determine if Medicaid will cover the service.

Service Authorization Policies and Procedures. Services in the Long-Term Care Benefit Package The MCO may use the Resource Allocation Decision Method (RAD) as its service authorization policy. If the MCO does not use the RAD, it must seek Department approval of alternative service authorization policies and procedures. The policies and procedures must address how new and continuing authorizations of services are approved and denied. The MCO may choose to create decision-making guidelines for more frequently used items and/or services. When the MCO wishes to utilize these guidelines as part of the RAD or alternative service authorization documentation (instead of documenting evidence), the guidelines must be approved by the Department. Services shall be authorized in a manner that reflects the member’s ongoing need for such services and supports as determined through the comprehensive assessment and consistent with the member-centered plan. Acute and Primary Care Services in the Partnership and PACE Benefit Package Packages The MCO shall have documented and Department-approved service authorization policies and procedures for services in the acute and primary care benefit package. Policies and procedures may differ from the authorization policies and procedures for services in the long-term care benefit package, and may be based on accepted clinical practices. Decisions about the authorization of services in the acute and primary care benefit package may be made outside of the IDT by other clinical professionals with consideration for member preferences. Authorization of Medicare Services in the Partnership and PACE Benefit Packages for Dual Eligibles SNPs The MCO Notwithstanding any other provision of this section, pursuant to their status as Medicare Advantage-Prescription Drug (MA-PD) or PACE plans and their Medicare agreement or contract with CMS, MCOs in making authorization decisions about Medicare coverable services for dual eligible members in Partnership or PACE shall coordinate first use and authorize the delivery of covered Medicare, Medicaid, and long-term care services using aligned care management by first using follow Medicare coverage and authorization policies, procedures and requirementsrequirements rather than the RAD or other Department-approved service authorization policies and procedures used for the authorization of Medicaid services under this contract. If the MCO determines that Medicare will not cover the service, the MCO must then use and follow the Medicaid coverage rules, including the RAD, to determine if Medicaid will cover the service.

Service Authorization Policies and Procedures. Services in the Long-Term Care Benefit Package The MCO may use the Resource Allocation Decision Method (RAD) as its service authorization policy. If the MCO does not use the RAD, it must seek Department approval of alternative service authorization policies and procedures. The policies and procedures must address how new and continuing authorizations of services are approved and denied. The MCO may choose to create decision-making guidelines for more frequently used items and/or services. When the MCO wishes to utilize these guidelines as part of the RAD or alternative service authorization documentation (instead of documenting evidence), the guidelines must be approved by the Department. Services shall be authorized in a manner that reflects the member’s ongoing need for such services and supports as determined through the comprehensive assessment and consistent with the member-centered plan. Acute and Primary Care Services in the Partnership Benefit Package The MCO shall have documented and Department-approved service authorization policies and procedures for services in the acute and primary care benefit package. Policies and procedures may differ from the authorization policies and procedures for services in the long-term care benefit package, and may be based on accepted clinical practices. Decisions about the authorization of services in the acute and primary care benefit package may be made outside of the IDT by other clinical professionals with consideration for member preferences. Authorization of Medicare Services in the Partnership Benefit Package for Dual Eligibles SNPs The MCO Notwithstanding any other provision of this section, pursuant to their status as Medicare Advantage plans and their Medicare agreement or contract with CMS, MCOs in making authorization decisions about Medicare coverable services for dual eligible members in Partnership shall coordinate first use and authorize the delivery of covered Medicare, Medicaid, and long-term care services using aligned care management by first using follow Medicare coverage and authorization policies, procedures and requirementsrequirements rather than the RAD or other Department- approved service authorization policies and procedures used for the authorization of Medicaid services under this contract. If the MCO determines that Medicare will not cover the service, the MCO must then use and follow the Medicaid coverage rules, including the RAD, to determine if Medicaid will cover the service.