Services Needing Prior Approval or Notification. Some services require Prior Approval or review of clinical documentation before Benefits will be provided by the Plan. Some services require that we be notified that you have received services. If you have any questions or need assistance to determine which services require Prior Approval or notification, please visit xxx.xxxxxxxxxxxxx.xxx or call Member Services at 1-855-624-6463 (TTY/TDD: 711).
a. Services that require notification (see section 6 for more information about payment of claims) When obtaining services from Network Providers, the Network Provider is responsible for notifying Health Options. When obtaining Emergency Services from non-Network Providers, you are responsible for ensuring Health Options is notified. Health Options Medical Management must be notified in the following manner: • Notification to Health Options is required within 48 hours for all inpatient admissions. • Notification is required for OB Care (pregnancies/deliveries) within 24 hours of Observation Stay or within 48 hours of Admission; Prior Approval is required for all extended OB stays (beyond 48 hours vaginal delivery and 96 hours for cesarean section). Approval for OB stays will be approved consistent with Guidelines for Perinatal Care published by the American Academy of Pediatrics and the American College of Obstetrics and Gynecology. • Notification to Health Options is required within 24 hours of Observation stays. o Non-OB Observations: Prior Approval rules and policies apply to procedures and services provided during an Observation stay. Non-OB Observation stays are limited to 48 hours at which time the Member is admitted or discharged to a lower level of care. • If notification or Approval is not requested within the required timeframe Community Health Options may deny benefits for the period prior to the request. • Notification is required for inter-facility ambulance transportation to the nearest facility capable of providing the appropriate level of care.
b. Types of services that generally require Prior Approval or submission of clinical documentation for clinical review. The list represents service categories that require Prior Approval but is not all-inclusive. For full details visit xxxxx://xxx.xxxxxxxxxxxxx.xxx/health-care-professionals/professional-document-and-forms/ • Prior Approval is required for all observation and inpatient admissions unless otherwise noted • Prior Approval is required for Acute Rehabilitation, Skilled Nursing Facilities, services...
Services Needing Prior Approval or Notification. Some services require Prior Approval or review of clinical documentation before Benefits will be provided by the Plan. Some services require that we be notified that you have received services. If you have any questions or need assistance to determine which services require Prior Approval or notification, please visit xxx.xxxxxxxxxxxxx.xxx or call Member Services at 1-855-624-6463 (TTY/TDD: 711). When receiving services from a non-Network Provider, if you fail to obtain Prior Approval for a service requiring Prior Approval, or if you fail to submit timely notification for a service that requires notification, you may not receive Benefits for that service and you may be responsible for the full cost of the service.
a. Services that require notification (see section 6 for more information about payment of claims) If notification or Approval is not requested within the required timeframe Community Health Options may deny benefits for the period prior to the request. Unless otherwise stated, services that require notification are subject to Medical Necessity review. When obtaining services from Network Providers, the Network Provider is responsible for notifying Health Options. When obtaining services from non-Network Providers, you are responsible for ensuring Health Options is notified. Health Options Medical Management must be notified in the following manner: Admissions: • Notification to Health Options is required within 48 hours for all Acute Care (Hospital) and inpatient scheduled and unscheduled admissions. • Notification to Health Options is required within 48 hours for Medical Withdrawal Management admissions. SAMPLE • All admissions are subject to medical necessity review. Ambulatory Services: • Crisis evaluations require notification within 10 business days (medical necessity review is waived). Home Health: • Notification to Health Options within 48 hours of 1st visit is required. • Prior Approval is required for Out-of-Network services. Inter-facility Transfers: • Notification to Health Options is required by the sending facility prior to inter-facility transfers and associated ambulance transportation. Prior Approval is required for all interfacility air-ambulance transports. (Coverage is limited to the nearest facility capable of providing the appropriate level of care. Observation Stays: • Notification to Health Options is required within 48 hours for all Observation stays. o Non-OB Observations: Prior Approval rules and policies apply to the e...
