Common use of Service Authorization Clause in Contracts

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 services must submit the ACAP Residential Habilitation Services Request Form to BSASP along with any information or documentation needed to support the request to authorize Residential Habilitation Services. The Contractor must also provide BSASP with any documents BSASP requests as part of its review of the need for Residential Habilitation Services. BSASP will review the request to authorize Residential Habilitation Services within the time frames for authorization specified in this Section. J. The Supports Coordinator must submit the ISP in HCSis, along with supporting documentation, to the Behavioral Health Practitioner for authorization of the services as specified in the ISP. If the Team was unable to reach a consensus on which services to include in the ISP or the amount, duration, or scope of a service include in the ISP, the Supports Coordinator must identify which services the Team did not reach consensus on and explain the position of each Team member. X. Following submission of the ISP in HCSis, the Behavioral Health Practitioner must, in consultation with the Medical and Clinical Directors, as appropriate, resolve any areas in the ISP on which the Team did not reach consensus and decide whether to authorize services for the Participant in accordance with the timelines outlined in Section 2.4.O. The Behavioral Health Practitioner may: 1. Authorize services as specified on the ISP, 2. Deny one or more services or authorize a different amount, duration, or scope of one or more services in the ISP, or 3. Request additional information from the Team to support the services included in the ISP or the amount, duration, or scope of a service included in the ISP. L. The Contractor must enter the decision to approve and authorize services into HCSis and communicate the decision in writing to the Participant or the Participant's representative, as appropriate, and the prescribing Provider, if the prescribing Provider is not a member of the Team. The Contractor must include a copy of the updated ISP along with the written notice of the decision to the Participant or the Participant’s representative, as appropriate. M. If services are not approved as requested, the Contractor must notify the Participant or the Participant's representative, as appropriate, the Participant’s Supports Coordinator, and the prescribing Provider, if the prescribing Provider is not a member of the Team, of the decision using the appropriate template supplied by the Department in Appendix N. N. The Contractor is permitted to place appropriate limits on a service for the purpose of utilization control, provided that: 1. The services supporting Participants with ongoing or chronic conditions who require long-term services and supports are authorized in such a manner that reflects the Participant’s ongoing need for such services and supports. 2. Family planning services are provided in a manner that protects and enables the Participant’s freedom to choose the method of family planning used. 1. Standard Service Authorizations a. The Contractor must notify the Participant or the Participant's representative, as appropriate, of the decision to approve or deny a request for services or to authorize a service in an amount, duration, or scope less than requested as expeditiously as the Participant's condition requires, at least orally, no later than five (5) days after receiving the request for service unless additional information is needed. b. If no additional information is needed, the Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Support Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. c. If additional information is needed to make a decision, the Contractor must request such information within three (3) days of receiving the request and allow seven (7) days for submission of the additional information. If the Contractor requests additional information, the Contractor must notify the Participant or the Participant's representative, as appropriate, on the date the additional information is requested, using the template found in Appendix F. i. If the requested information is provided within seven (7) days, the Contractor must make the decision to approve or deny the service and notify the Participant or the Participant's representative, as appropriate, of the decision orally within two

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 2.1.Y 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.Z2.1.Y, 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- 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 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 services must submit the ACAP Residential Habilitation Services Request Form to BSASP along with any information or documentation needed to support the request to authorize Residential Habilitation Services. The Contractor must also provide BSASP with any documents BSASP requests as part of its review of the need for Residential Habilitation Services. BSASP will review the request to authorize Residential Habilitation Services within the time frames for authorization specified in this Section. J. The I. Within five (5) days of the Team meeting to develop ISP the Supports Coordinator must submit the ISP in HCSis, along with and supporting documentation, documentation to the Behavioral Health Practitioner for authorization of the services as specified in the ISP. If the Team was unable to reach a consensus on which services to include in the an ISP or the amount, duration, or scope of a service include in the an ISP, the Supports Coordinator must identify the services on which the Team did and did not reach consensus and explain the positions taken by the Team members for the services on which the Team did not reach consensus on and explain the position of each Team memberconsensus. X. Following submission of the ISP in HCSis, After the Behavioral Health Practitioner receives the ISP from the Team, he or she must, in consultation with the Medical and Clinical Directors, Directors as appropriate, resolve any areas in the ISP on which the Team did not reach consensus and decide whether to authorize services for the Participant in accordance with the timelines outlined in Section 2.4.O. Participant. The Behavioral Health Practitioner may: 1. Authorize services as specified on the ISP, 2. Deny one or more services or authorize a different amount, duration, or scope of one or more services in the ISP, or 3. Request additional information from the Team to support the services included in the ISP or the amount, duration, or scope of a service included in the ISP. L. K. The Contractor decision on the ISP must enter be communicated to the decision to approve Supports Coordinator and authorize services into HCSis and communicate the decision PCP in writing to at the same time the Participant or the Participant's representative, as appropriate, and the prescribing Provider, if the prescribing Provider is not a member of the Team. The Contractor must include a copy of the updated ISP along with the written notice notified of the decision to on the Participant or ISP. The notice must explain the Participant’s representative, as appropriaterationale for the decision and identify any changes between the authorized ISP and the ISP submitted by the Team. M. If services are not approved as requested, the L. The Contractor must notify the Participant or the Participant's representative, representative as appropriate, in writing using a document approved by the Department, in addition to the notification to the Supports Coordinator and PCP, of any decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice must include the decision; the specific reasons for the decision including the right of the Participant to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested, including medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits; instructions on how a Participant can file a Complaint or Grievance if he or she does not agree with the decision and, after exhausting the Complaint or Grievance process, request a Fair Hearing; information on the Participant's right to request expedited review if the Participant's treating practitioner believes that the Participant's life, health, or ability to regain maximum function would be seriously jeopardized absent provision of the service in dispute; the Participant's right to have benefits continue pending resolution of the Complaint or Grievance; and how to request that benefits be continued; and the Participant’s Supports Coordinatorright to be free from discrimination on the basis of race, color, national origin, sex, age, or disability. The notice must be written in language that is readily understandable by a layperson, at a fourth-grade reading level whenever possible and include the prescribing Provider, if the prescribing Provider is not a member of the Team, of the decision using the appropriate template supplied by the Department taglines listed in Appendix N.Attachment V. N. M. The Contractor is permitted to place appropriate limits on a service for the purpose of utilization control, provided that: 1. The services supporting Participants with ongoing or chronic conditions who require long-term services and supports are authorized in such a manner that reflects the Participant’s ongoing need for such services and supports. 2. Family planning services are provided in a manner that protects and enables the Participant’s freedom to choose the method of family planning used. 1. Standard N. Time Frames for Service Authorizations a. The Contractor must notify the Participant or the Participant's representative, as appropriate, of the decision to approve or deny a request for services or to authorize a service in an amount, duration, or scope less than requested as expeditiously as the Participant's condition requires, at least orally, no later than five (5) days after receiving the request for service unless additional information is needed. b. If no additional information is needed, the Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Support Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. c. If additional information is needed to make a decision, the Contractor must request such information within three (3) days of receiving the request and allow seven (7) days for submission of the additional information. If the Contractor requests additional information, the Contractor must notify the Participant or the Participant's representative, as appropriate, on the date the additional information is requested, using the template found in Appendix F. i. If the requested information is provided within seven (7) days, the Contractor must make the decision to approve or deny the service and notify the Participant or the Participant's representative, as appropriate, of the decision orally within twoAuthorization:

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.Crisis 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- inclusivemost•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 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 services must submit the ACAP Residential Habilitation Services Request Form to BSASP along with any information or documentation needed to support the request to authorize Residential Habilitation Services. The Contractor must also provide BSASP with any documents BSASP requests as part of its review of the need for Residential Habilitation Services. BSASP will review the request to authorize Residential Habilitation Services within the time frames for authorization specified in this Section. J. The Supports Coordinator must submit the ISP in HCSis, along with supporting documentation, to the Behavioral Health Practitioner for authorization of the services as specified in the ISP. If the Team was unable to reach a consensus on which services to include in the ISP or the amount, duration, or scope of a service to include in the ISP, the Supports Coordinator must identify which services the Team did not reach consensus on and explain the position of each Team member. X. Following submission of the ISP in HCSis, the Behavioral Health Practitioner must, in consultation with the Medical and Clinical Directors, as appropriate, resolve any areas in the ISP on which the Team did not reach consensus and decide whether to authorize services for the Participant in accordance with the timelines outlined in Section 2.4.O. The Behavioral Health Practitioner may: 1. Authorize services as specified on the ISP, 2. Deny one or more services or authorize a different amount, duration, or scope of one or more services in the ISP, or 3. Request additional information from the Team to support the services included in the ISP or the amount, duration, or scope of a service included in the ISP. L. The Contractor must enter the decision to approve and authorize services into HCSis and communicate the decision in writing to the Participant or the Participant's representative, as appropriate, and the prescribing Provider, if the prescribing Provider is not a member of the Team. The Contractor must include a copy of the updated ISP along with the written notice of the decision to the Participant or the Participant’s representative, as appropriate. M. If services are not approved as requested, the Contractor must notify the Participant or the Participant's representative, as appropriate, the Participant’s Supports Coordinator, and the prescribing Provider, if the prescribing Provider is not a member of the Team, of the decision using the appropriate template supplied by the Department in Appendix N. N. The Contractor is permitted to place appropriate limits on a service for the purpose of utilization control, provided that: 1. The services supporting Participants with ongoing or chronic conditions who require long-term services and supports are authorized in such a manner that reflects the Participant’s ongoing need for such services and supports. 2. Family planning services are provided in a manner that protects and enables the Participant’s freedom to choose the method of family planning used. 1. Standard Service Authorizations a. The Contractor must notify the Participant or the Participant's representative, as appropriate, of the decision to approve or deny a request for services or to authorize a service in an amount, duration, or scope less than requested as expeditiously as the Participant's condition requires, at least orally, no later than five (5) days after receiving the request for service unless additional information is needed. b. If no additional information is needed, the Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Support Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. c. If additional information is needed to make a decision, the Contractor must request such information within three (3) days of receiving the request and allow seven (7) days for submission of the additional information. If the Contractor requests additional information, the Contractor must notify the Participant or the Participant's representative, as appropriate, on the date the additional information is requested, using the template found in Appendix F. i. If the requested information is provided within seven (7) days, the Contractor must make the decision to approve or deny the service and notify the Participant or the Participant's representative, as appropriate, of the decision orally within twotwo (2) business days of receipt of the additional information. The Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. ii. If the requested information is not received within seven (7) days, the Contractor must make the decision to approve or deny the service based upon the available information and notify the Participant or the Participant's representative, as appropriate, of the decision orally within two (2) business days after the additional information was to have been received. The Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made.

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- 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 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 services must submit the ACAP Residential Habilitation Services Request Form to BSASP along with any information or documentation needed to support the request to authorize Residential Habilitation Services. The Contractor must also provide BSASP with any documents BSASP requests as part of its review of the need for Residential Habilitation Services. BSASP will review the request to authorize Residential Habilitation Services within the time frames for authorization specified in this Section. J. The Supports Coordinator must submit the ISP in HCSis, along with supporting documentation, to the Behavioral Health Practitioner for authorization of the services as specified in the ISP. If the Team was unable to reach a consensus on which services to include in the ISP or the amount, duration, or scope of a service to include in the ISP, the Supports Coordinator must identify which services the Team did not reach consensus on and explain the position of each Team member. X. K. Following submission of the ISP in HCSis, the Behavioral Health Practitioner must, in consultation with the Medical and Clinical Directors, as appropriate, resolve any areas in the ISP on which the Team did not reach consensus and decide whether to authorize services for the Participant in accordance with the timelines outlined in Section 2.4.O. The Behavioral Health Practitioner may: 1. Authorize services as specified on the ISP, 2. Deny one or more services or authorize a different amount, duration, or scope of one or more services in the ISP, or 3. Request additional information from the Team to support the services included in the ISP or the amount, duration, or scope of a service included in the ISP. L. The Contractor must enter the decision to approve and authorize services into HCSis and communicate the decision in writing to the Participant or the Participant's representative, as appropriate, and the prescribing Provider, if the prescribing Provider is not a member of the Team. The Contractor must include a copy of the updated ISP along with the written notice of the decision to the Participant or the Participant’s representative, as appropriate. M. If services are not approved as requested, the Contractor must notify the Participant or the Participant's representative, as appropriate, the Participant’s Supports Coordinator, and the prescribing Provider, if the prescribing Provider is not a member of the Team, of the decision using the appropriate template supplied by the Department in Appendix N. N. The Contractor is permitted to place appropriate limits on a service for the purpose of utilization control, provided that: 1. The that the services supporting Participants with ongoing or chronic conditions who require long-term services and supports are authorized in such a manner that reflects the Participant’s ongoing need for such services and supports. 2. Family planning services are provided in a manner that protects and enables the Participant’s freedom to choose the method of family planning used.O. Time Frames for Service Authorization: 1. Standard Service Authorizations a. The Contractor must notify the Participant or the Participant's representative, as appropriate, of the decision to approve or deny a request for services or to authorize a service in an amount, duration, or scope less than requested as expeditiously as the Participant's condition requires, at least orally, no later than five (5) days after receiving the request for service unless additional information is needed. b. If no additional information is needed, the Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Support Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. c. If additional information is needed to make a decision, the Contractor must request such information within three (3) days of receiving the request and allow seven (7) days for submission of the additional information. If the Contractor requests additional information, the Contractor must notify the Participant or the Participant's representative, as appropriate, on the date the additional information is requested, using the template found in Appendix F. i. If the requested information is provided within seven (7) days, the Contractor must make the decision to approve or deny the service and notify the Participant or the Participant's representative, as appropriate, of the decision orally within twotwo (2) business days of receipt of the additional information. The Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. ii. If the requested information is not received within seven (7) days, the Contractor must make the decision to approve or deny the service based upon the available information and notify the Participant or the Participant's representative, as appropriate, of the decision orally within two (2) business days after the additional information was to have been received. The Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made.

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 2.1.Y 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.Z2.1.Y, 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 cope 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 Initial ISP and FBA-Based ISP, including the Crisis Intervention Plan and Behavioral Support Plan if applicablePlan. 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 BAS for review prior to authorization on the form provided by BSASP BAS, and include the FBA-Based ISP. The review by BSASP BAS will be within the time frames timeframes for authorization specified in this Section. I. . If the Contractor determines that a Participant needs Residential Habilitation Servicesservices, the Contractor prior to authorizing the services must submit the ACAP Residential Habilitation Services Request Form to BSASP BAS along with any information or documentation needed to support the request to authorize Residential Habilitation Servicesservices. The Contractor must also provide BSASP BAS with any documents BSASP BAS requests as part of its review of the need for Residential Habilitation Servicesservices. BSASP BAS will review the request to authorize Residential Habilitation Services services within the time frames timeframes for authorization specified in this Section. J. The I. Within five (5) days of the Team meeting to develop the Initial ISP or the FBA-Based ISP the Supports Coordinator must submit the Initial ISP in HCSis, along with or the FBA-Based ISP and supporting documentation, documentation to the Behavioral Health Practitioner for authorization of the services as specified in the Initial ISP or FBA-Based ISP. If the Team was unable to reach a consensus on which services to include in the an ISP or the amount, duration, or scope of a service include in the an ISP, the Supports Coordinator must identify the services on which the Team did and did not reach consensus and explain the positions taken by the Team members for the services on which the Team did not reach consensus on and explain the position of each Team memberconsensus. X. Following submission of the ISP in HCSis, J. After the Behavioral Health Practitioner receives the Initial ISP or the FBA Based ISP from the Team, he or she must, in consultation with the Medical and Clinical Directors, Director as appropriate, resolve any areas in the ISP on which the Team did not reach consensus and decide whether to authorize services for the Participant in accordance with the timelines outlined in Section 2.4.O. Participant. The Behavioral Health Practitioner may: 1. Authorize services as specified on the ISP, 2. Deny one or more services or authorize a different amount, duration, or scope of one or more services in the ISP, or 3. Request additional information from the Team to support the services included in the ISP or the amount, duration, or scope of a service included in the ISP. L. K. The Contractor decision on the Initial ISP and the FBA-Based ISP must enter be communicated to the decision to approve Supports Coordinator and authorize services into HCSis and communicate the decision PCP in writing to at the same time the Participant or the Participant's representative, as appropriate, and the prescribing Provider, if the prescribing Provider is not a member of the Team. The Contractor must include a copy of the updated ISP along with the written notice notified of the decision to on the Participant or ISP. The notice must explain the Participant’s representative, as appropriaterationale for the decision and identify any changes between the authorized ISP and the ISP submitted by the Team. M. If services are not approved as requested, the L. The Contractor must notify the Participant or the Participant's representative, representative as appropriate, in writing using a document approved by the Department, in addition to the notification to the Supports Coordinator and PCP, of any decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice must include the decision; the specific reasons for the decision; instructions on how a Participant can file a Grievance if he or she does not agree with the decision and, after exhausting the Grievance process, request a DHS Fair Hearing; information on the Participant’s Supports Coordinator's right to request expedited review if the Participant's treating practitioner believes that the Participant's life, health, or ability to regain maximum function would be seriously jeopardized absent provision of the service in dispute; and the prescribing Provider, if the prescribing Provider is not a member Participant's right to have benefits continue pending resolution of the Team, of the decision using the appropriate template supplied by the Department in Appendix N. N. The Contractor is permitted Grievance or DHS Fair Hearing; and how to place appropriate limits on a service for the purpose of utilization control, provided that: 1request that benefits be continued. The services supporting Participants with ongoing or chronic conditions who require longnotice must be written in language that is readily understandable by a layperson, at a fourth-term services and supports are authorized in such a manner that reflects the Participant’s ongoing need for such services and supportsgrade reading level whenever possible. 2. Family planning services are provided in a manner that protects and enables the Participant’s freedom to choose the method of family planning used.M. Time Frames for Service Authorization: 1. Standard Service Authorizations a. The Contractor must notify the Participant or the Participant's representative, as appropriate, of the decision to approve or deny a request for services or to authorize a service in an amount, duration, or scope less than requested as expeditiously as the Participant's condition requires, at least orally, no later than five (5) days after receiving the request for service unless additional information is needed. b. . If no additional information is needed, the Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Support Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. c. b. If additional information is needed to make a decision, the Contractor must request such information within three (3) days of receiving the request and allow seven (7) days for submission of the additional information. If the Contractor requests additional information, the Contractor must notify the Participant or the Participant's representative, as appropriate, on the date the additional information is requested, using the template found in Appendix F. i. If the requested information is provided within seven (7) days, the Contractor must make the decision to approve or deny the service and notify the Participant or the Participant's representative, as appropriate, of the decision orally within twoseven

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.Crisis 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- inclusivemost•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 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 services must submit the ACAP Residential Habilitation Services Request Form to BSASP along with any information or documentation needed to support the request to authorize Residential Habilitation Services. The Contractor must also provide BSASP with any documents BSASP requests as part of its review of the need for Residential Habilitation Services. BSASP will review the request to authorize Residential Habilitation Services within the time frames for authorization specified in this Section. J. The Supports Coordinator must submit the ISP in HCSis, along with supporting documentation, to the Behavioral Health Practitioner for authorization of the services as specified in the ISP. If the Team was unable to reach a consensus on which services to include in the ISP or the amount, duration, or scope of a service to include in the ISP, the Supports Coordinator must identify which services the Team did not reach consensus on and explain the position of each Team member. X. K. Following submission of the ISP in HCSis, the Behavioral Health Practitioner must, in consultation with the Medical and Clinical Directors, as appropriate, resolve any areas in the ISP on which the Team did not reach consensus and decide whether to authorize services for the Participant in accordance with the timelines outlined in Section 2.4.O. The Behavioral Health Practitioner may: 1. Authorize services as specified on the ISP, 2. Deny one or more services or authorize a different amount, duration, or scope of one or more services in the ISP, or 3. Request additional information from the Team to support the services included in the ISP or the amount, duration, or scope of a service included in the ISP. L. The Contractor must enter the decision to approve and authorize services into HCSis and communicate the decision in writing to the Participant or the Participant's representative, as appropriate, and the prescribing Provider, if the prescribing Provider is not a member of the Team. The Contractor must include a copy of the updated ISP along with the written notice of the decision to the Participant or the Participant’s representative, as appropriate. M. If services are not approved as requested, the Contractor must notify the Participant or the Participant's representative, as appropriate, the Participant’s Supports Coordinator, and the prescribing Provider, if the prescribing Provider is not a member of the Team, of the decision using the appropriate template supplied by the Department in Appendix N. N. The Contractor is permitted to place appropriate limits on a service for the purpose of utilization control, provided that: 1. The services supporting Participants with ongoing or chronic conditions who require long-term services and supports are authorized in such a manner that reflects the Participant’s ongoing need for such services and supports. 2. Family planning services are provided in a manner that protects and enables the Participant’s freedom to choose the method of family planning used. 1. Standard Service Authorizations a. The Contractor must notify the Participant or the Participant's representative, as appropriate, of the decision to approve or deny a request for services or to authorize a service in an amount, duration, or scope less than requested as expeditiously as the Participant's condition requires, at least orally, no later than five (5) days after receiving the request for service unless additional information is needed. b. If no additional information is needed, the Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Support Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. c. If additional information is needed to make a decision, the Contractor must request such information within three (3) days of receiving the request and allow seven (7) days for submission of the additional information. If the Contractor requests additional information, the Contractor must notify the Participant or the Participant's representative, as appropriate, on the date the additional information is requested, using the template found in Appendix F. i. If the requested information is provided within seven (7) days, the Contractor must make the decision to approve or deny the service and notify the Participant or the Participant's representative, as appropriate, of the decision orally within twotwo (2) business days of receipt of the additional information. The Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. ii. If the requested information is not received within seven (7) days, the Contractor must make the decision to approve or deny the service based upon the available information and notify the Participant or the Participant's representative, as appropriate, of the decision orally within two (2) business days after the additional information was to have been received. The Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made.

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 2.1.Y 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.Z2.1.Y, 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 BAS for review prior to authorization on the form provided by BSASP BAS, and include the ISP. The review by BSASP BAS 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 services must submit the ACAP Residential Habilitation Services Request Form to BSASP BAS along with any information or documentation needed to support the request to authorize Residential Habilitation Services. The Contractor must also provide BSASP BAS with any documents BSASP BAS requests as part of its review of the need for Residential Habilitation Services. BSASP BAS will review the request to authorize Residential Habilitation Services within the time frames for authorization specified in this Section. J. The I. Within five (5) days of the Team meeting to develop ISP the Supports Coordinator must submit the ISP in HCSis, along with and supporting documentation, documentation to the Behavioral Health Practitioner for authorization of the services as specified in the ISP. If the Team was unable to reach a consensus on which services to include in the an ISP or the amount, duration, or scope of a service include in the an ISP, the Supports Coordinator must identify the services on which the Team did and did not reach consensus and explain the positions taken by the Team members for the services on which the Team did not reach consensus on and explain the position of each Team memberconsensus. X. Following submission of the ISP in HCSis, J. After the Behavioral Health Practitioner receives the ISP from the Team, he or she must, in consultation with the Medical and Clinical Directors, Directors as appropriate, resolve any areas in the ISP on which the Team did not reach consensus and decide whether to authorize services for the Participant in accordance with the timelines outlined in Section 2.4.O. Participant. The Behavioral Health Practitioner may: 1. Authorize services as specified on the ISP, 2. Deny one or more services or authorize a different amount, duration, or scope of one or more services in the ISP, or 3. Request additional information from the Team to support the services included in the ISP or the amount, duration, or scope of a service included in the ISP. L. K. The Contractor decision on the ISP must enter be communicated to the decision to approve Supports Coordinator and authorize services into HCSis and communicate the decision PCP in writing to at the same time the Participant or the Participant's representative, as appropriate, and the prescribing Provider, if the prescribing Provider is not a member of the Team. The Contractor must include a copy of the updated ISP along with the written notice notified of the decision to on the Participant or ISP. The notice must explain the Participant’s representative, as appropriaterationale for the decision and identify any changes between the authorized ISP and the ISP submitted by the Team. M. If services are not approved as requested, the L. The Contractor must notify the Participant or the Participant's representative, representative as appropriate, in writing using a document approved by the Department, in addition to the notification to the Supports Coordinator and PCP, of any decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice must include the decision; the specific reasons for the decision including the right of the Participant to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested, including medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits; instructions on how a Participant can file a Complaint or Grievance if he or she does not agree with the decision and, after exhausting the Complaint or Grievance process, request a Fair Hearing; information on the Participant's right to request expedited review if the Participant's treating practitioner believes that the Participant's life, health, or ability to regain maximum function would be seriously jeopardized absent provision of the service in dispute; the Participant's right to have benefits continue pending resolution of the Complaint or Grievance; and how to request that benefits be continued; and the Participant’s Supports Coordinatorright to be free from discrimination on the basis of race, color, national origin, sex, age, or disability. The notice must be written in language that is readily understandable by a layperson, at a fourth-grade reading level whenever possible and include the prescribing Provider, if the prescribing Provider is not a member of the Team, of the decision using the appropriate template supplied by the Department taglines listed in Appendix N.Attachment V. N. M. The Contractor is permitted to place appropriate limits on a service for the purpose of utilization control, provided that: 1. The services supporting Participants with ongoing or chronic conditions who require long-term services and supports are authorized in such a manner that reflects the Participant’s ongoing need for such services and supports. 2. Family planning services are provided in a manner that protects and enables the Participant’s freedom to choose the method of family planning used. 1. Standard N. Time Frames for Service Authorizations a. The Contractor must notify the Participant or the Participant's representative, as appropriate, of the decision to approve or deny a request for services or to authorize a service in an amount, duration, or scope less than requested as expeditiously as the Participant's condition requires, at least orally, no later than five (5) days after receiving the request for service unless additional information is needed. b. If no additional information is needed, the Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Support Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. c. If additional information is needed to make a decision, the Contractor must request such information within three (3) days of receiving the request and allow seven (7) days for submission of the additional information. If the Contractor requests additional information, the Contractor must notify the Participant or the Participant's representative, as appropriate, on the date the additional information is requested, using the template found in Appendix F. i. If the requested information is provided within seven (7) days, the Contractor must make the decision to approve or deny the service and notify the Participant or the Participant's representative, as appropriate, of the decision orally within twoAuthorization: