Common use of Service Authorization Clause in Contracts

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. A. Contractor shall implement mechanisms to assure authorization decision standards are met in accordance with Mental Behavioral Health Information Notices (BHINs) 22-016 and Substance Use Disorder Services (MHSUDS) Information Notice 1922-026017, 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. The Contractor shall comply with authorization timeframes in accordance with BHINs 22-016 and 22-017, 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, as well as any applicable state and federal regulations. (42 C.F.R. § 438.910(d).) C. For cases in which a provider indicates, or the Contractor determines, that following the standard authorization decisionstimeframe 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 not to exceed 14 calendar days following and no later than 72 hours after receipt of the request for service, with a possible extension of . The Contractor may extend the 72-hour time period by up to 14 additional calendar days when: 1) The beneficiaryif the beneficiary requests an extension, or if the provider, requests extension; or 2) The Contractor justifies (to the Department upon request) ), and documents, a need for additional information and how the extension is in the beneficiary’s interest. (42 C.F.R. § 438.210(d)(1438.210(d)(2)) D. The Contractor shall act on an authorization request for treatment for urgent conditions within one hour of the request. (Cal. Code Regs., tit. 9, §§ 1810.253 1810.405, subd. (c)).