Common use of Service Authorization Policies and Procedures Clause in Contracts

Service Authorization Policies and Procedures. a. 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. b. Acute and Primary Care Services in the Partnership and PACE Benefit Packages The MCO shall have documented and Department-approved service authorization policies and procedures for services in the acute and primary care benefit package. Such 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.

Service Authorization Policies and Procedures. a. 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. b. Acute and Primary Care Services in the Partnership and PACE Benefit Packages The MCO shall have documented and Department-approved service authorization policies and procedures for services in the acute and primary care benefit package. Such The MCO’s service authorization policies and procedures must be applied no more stringently for mental health/substance abuse benefits than they are for medical/surgical benefits as required by the Mental Health Parity and Addiction Equity Act. The MCO’s 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.

Service Authorization Policies and Procedures. a. Services in the Long-Term Care Benefit Package For the services in the long-term care benefit package the MCO shall have documented and Department-approved service authorization policies and procedures for processing requests for initial and continuing authorizations of services and for determining approval or denial of services. The MCO may use the Resource Allocation Decision Method (RAD) ), as its service authorization policydeveloped and disseminated by the Department. If the MCO does not use the RAD, it must seek Department approval of alternative service authorization policies and procedures. The MCO may use the RAD as its general service authorization policy and seek approval for authorization policies and procedures must address how new and continuing authorizations of that it will use for specified 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 Departmentitems. b. Acute and Primary Care Services in the Partnership and PACE Benefit Packages The MCO shall have documented and Department-approved service authorization policies and procedures for services in the acute and primary care benefit package. Such 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.