Common use of Services Not Subject to Prior Approval Clause in Contracts

Services Not Subject to Prior Approval. The Contractor will assure coverage of Emergency Conditions and Urgent Care services. The Contractor must not require prior approval for the following services: Any services for Emergency Conditions as defined in 42 C.F.R 422.113(b)(1) and 438.114(a) (which includes emergency Behavioral Health care); Urgent Care sought outside of the Service Area; Urgent Care under unusual or extraordinary circumstances provided in the Service Area when the contracted medical provider is unavailable or inaccessible; Family planning services; Out‑of‑area renal dialysis services; Prescription drugs as required in Appendix F; Inpatient Substance Use Disorder Services (American Society of Addition Medicine (ASAM) Level 4) as defined in Appendix B, Exhibit 2. Medical necessity shall be determined by the treating clinician in consultation with the Enrollee; Acute Treatment Services for Substance Use Disorders (ASAM Level 3.7) (ATS), as defined in Appendix B, Exhibit 2. Contractor shall require providers delivering ATS to provide Contractor, within forty‑eight (48) hours of an Enrollee’s admission, with notification of admission of an Enrollee and an initial treatment plan for such Enrollee. Contractor may establish the manner and method of such notification but may not require the provider to submit any information other than the name of the Enrollee, information regarding the Enrollee’s coverage with the Contractor, and the provider’s initial treatment plan. Contractor may not use failure to provide such notice as the basis for denying claims for services provided. Medical necessity shall be determined by the treating clinician in consultation with the Enrollee; Clinical Support Services for Substance Use Disorders (ASAM Level 3.5) (CSS), as defined in Appendix B, Exhibit 2. The Contractor shall require providers delivering CSS to provide the Contractor, within 48 hours of an Enrollee’s admission, with notification of admission of an Enrollee and an initial treatment plan for such Enrollee. The Contractor may establish the manner and method of such notification but may not require the provider to submit any information other than the name of the Enrollee, information regarding the Enrollee’s coverage with the Contractor, and the provider’s initial treatment plan. Contractor may not use failure to provide such notice as the basis for denying claims for services provided. Medical necessity shall be determined by the treating clinician in consultation with the Enrollee; Outpatient Services for covered substance use disorder treatment services: The following Behavioral Health Outpatient Services, as defined in Appendix B, Exhibit 2: Couples/Family Treatment, Group Treatment, Individual Treatment, and Ambulatory Detoxification (Level II.d); Day Treatment: Structured Outpatient Addiction Program (SOAP), as defined in Appendix B, Exhibit 2; Intensive Outpatient Program (IOP), as defined in Appendix B, Exhibit 2; and Partial Hospitalization, as defined in Appendix B, Exhibit 2, for American Society of Addiction Level 2.5, with short‑term day or evening mental health programming available five (5) to seven (7) days per week. Clinically Managed Population‑Specific High Intensity Residential Services (ASAM Level 3.3), as defined in Appendix B, Exhibit 2, as directed by EOHHS; Transitional Support Services (TSS) for Substance Use Disorders (ASAM Level 3.1), as defined in Appendix B, Exhibit 2, as directed by EOHHS; Additional SUD Treatment Services in accordance with Section 2.8.6.1.; The initiation or re‑initiation of a buprenorphine/naloxone prescription of 32 mg/day or less, for either brand formulations (e.g. Suboxone™, Zubsolv™, Bunavail™) or generic formulations, provided, however, that the Contractor may have a preferred formulation. Contractor may establish review protocols for continuing prescriptions. Notwithstanding the foregoing, the Contractor may implement prior authorization for buprenorphine (Subutex™) and limit coverage to pregnant or lactating women and individuals allergic to naloxone, provided such limitations are clinically appropriate.” Authorization of Services In accordance with 42 C.F.R. § 438.210, the Contractor shall authorize services as follows: For the processing of Service Requests for initial and continuing authorizations of services, the Contractor shall: Have in place and follow written policies and procedures; Have in place procedures to allow Enrollees, authorized representatives, and providers to initiate requests for provisions of services; Have policies and procedures to ensure Service Requests are processed in accordance with the required timelines outlined in Section 2.9.4.7; Have in effect mechanisms to ensure the consistent application of review criteria for authorization decisions; Have in place an authorization process for the LTSS referenced in Appendix A and defined in Appendix B; and Consult with the Enrollee and requesting provider when appropriate. The Contractor shall ensure that a PCP and a Behavioral Health Provider are available twenty‑four (24) hours a day for timely authorization of all Medically Necessary Services and to coordinate transfer of stabilized Enrollees in the emergency department, if necessary. Such individuals shall be familiar with the Massachusetts delivery system, standards and practices of care in Massachusetts, and best practices in the types of services they authorize. The Contractor’s guidelines for Medically Necessary Services shall comport with the definition of Medically Necessary Services as described in Section 1 and with Section 2.4.2, and shall, at a minimum, be no more restrictive than the cumulative Medicare and Medicaid scopes of services. Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested shall be made by a health care professional who has appropriate clinical expertise in treating the Enrollee’s medical condition, performing the procedure, or providing the treatment, and who is familiar with the Massachusetts delivery system, the standards and practices of care in Massachusetts, and best practices in the types of services they authorize. In addition to the foregoing requirements,. Behavioral Health Services denials shall be rendered by board‑certified or board‑eligible psychiatrists or by a clinician licensed with the same or similar specialty as the Behavioral Health Services being denied, except in cases of denials of service for psychological testing, which shall be rendered by a qualified psychologist. The Contractor shall assure that all Behavioral Health authorization and utilization management activities are in compliance with 42 U.S.C. § 1396u‑2(b)(8). Contractor must comply with the requirements for demonstrating parity for both cost sharing (co‑payments) and treatment limitations between mental health and substance use disorder and medical/surgical inpatient, outpatient and pharmacy benefits. The Contractor shall authorize PAS to meet Xxxxxxxxx’ needs for assistance with ADLs and IADLs. The Contractor may consider the Enrollee’s need for physical assistance as well as cueing or monitoring in order for the Enrollee to perform an ADL or IADL. Authorizations must consider the medical and independent living needs of the Enrollee.

Services Not Subject to Prior Approval. The Contractor will assure coverage of Emergency Conditions and Urgent Care services. The Contractor must not require prior approval for the following services: Any services for Emergency Conditions as defined in 42 C.F.R 422.113(b)(1) and 438.114(a) (which includes emergency Behavioral Health care); Urgent Care sought outside of the Service Area; Urgent Care under unusual or extraordinary circumstances provided in the Service Area when the contracted medical provider is unavailable or inaccessible; Family planning services; Out‑of‑area renal dialysis services; Prescription drugs as required in Appendix F; Inpatient Substance Use Disorder Services (American Society of Addition Medicine (ASAM) Level 4) as defined in Appendix B, Exhibit 2. Medical necessity shall be determined by the treating clinician in consultation with the Enrollee; Acute Treatment Services for Substance Use Disorders (ASAM Level 3.7) (ATS), as defined in Appendix B, Exhibit 2. Contractor shall require providers delivering ATS to provide Contractor, within forty‑eight (48) hours of an Enrollee’s admission, with notification of admission of an Enrollee and an initial treatment plan for such Enrollee. Contractor may establish the manner and method of such notification but may not require the provider to submit any information other than the name of the Enrollee, information regarding the Enrollee’s coverage with the Contractor, and the provider’s initial treatment plan. Contractor may not use failure to provide such notice as the basis for denying claims for services provided. Medical necessity shall be determined by the treating clinician in consultation with the Enrollee; Clinical Support Services for Substance Use Disorders (ASAM Level 3.5) (CSS), as defined in Appendix B, Exhibit 2. The Contractor shall require providers delivering CSS to provide the Contractor, within 48 hours of an Enrollee’s admission, with notification of admission of an Enrollee and an initial treatment plan for such Enrollee. The Contractor may establish the manner and method of such notification but may not require the provider to submit any information other than the name of the Enrollee, information regarding the Enrollee’s coverage with the Contractor, and the provider’s initial treatment plan. Contractor may not use failure to provide such notice as the basis for denying claims for services provided. Medical necessity shall be determined by the treating clinician in consultation with the Enrollee; Outpatient Services for covered substance use disorder treatment services: The following Behavioral Health Outpatient Services, as defined in Appendix B, Exhibit 2: Couples/Family Treatment, Group Treatment, Individual Treatment, and Ambulatory Detoxification (Level II.d); Day Treatment: Structured Outpatient Addiction Program (SOAP), as defined in Appendix B, Exhibit 2; Intensive Outpatient Program (IOP), as defined in Appendix B, Exhibit 2; and Partial Hospitalization, as defined in Appendix B, Exhibit 2, for American Society of Addiction Level 2.5, with short‑term day or evening mental health programming available five (5) to seven (7) days per week. Clinically Managed Population‑Specific High Intensity Residential Services (ASAM Level 3.3), as defined in Appendix B, Exhibit 2, as directed by EOHHS; Transitional Support Services (TSS) for Substance Use Disorders (ASAM Level 3.1), as defined in Appendix B, Exhibit 2, as directed by EOHHS; Additional SUD Treatment Services in accordance with Section 2.8.6.1.; The initiation or re‑initiation of a buprenorphine/naloxone prescription of 32 mg/day or less, for either brand formulations (e.g. Suboxone™, Zubsolv™, Bunavail™) or generic formulations, provided, however, that the Contractor may have a preferred formulation. Contractor may establish review protocols for continuing prescriptions. Notwithstanding the foregoing, the Contractor may implement prior authorization for buprenorphine (Subutex™) and limit coverage to pregnant or lactating women and individuals allergic to naloxone, provided such limitations are clinically appropriate.” Authorization of Services In accordance with 42 C.F.R. § 438.210, the Contractor shall authorize services as follows: For the processing of Service Requests for initial and continuing authorizations of services, the Contractor shall: Have in place and follow written policies and procedures; Have in place procedures to allow Enrollees, authorized representatives, and providers to initiate requests for provisions of services; Have policies and procedures to ensure Service Requests are processed in accordance with the required timelines outlined in Section 2.9.4.7; Have in effect mechanisms to ensure the consistent application of review criteria for authorization decisions; Have in place an authorization process for the LTSS referenced in Appendix A and defined in Appendix B; and Consult with the Enrollee and requesting provider when appropriate. The Contractor shall ensure that a PCP and a Behavioral Health Provider are available twenty‑four (24) hours a day for timely authorization of all Medically Necessary Services and to coordinate transfer of stabilized Enrollees in the emergency department, if necessary. Such individuals shall be familiar with the Massachusetts delivery system, standards and practices of care in Massachusetts, and best practices in the types of services they authorize. The Contractor’s medical necessity guidelines for Medically Necessary Services shall comport with the definition of Medically Necessary Services as described in Section 1 and with Section 2.4.2, and shallmust, at a minimum, be no more restrictive than the cumulative Medicare standards for acute services and prescription drugs and Medicaid scopes of servicesstandards for LTSS. Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested shall must be made by a health care professional who has appropriate clinical expertise in treating the Enrollee’s medical condition, performing the procedure, or providing the treatment, and who is familiar with the Massachusetts delivery system, the standards and practices of care in Massachusetts, and best practices in the types of services they authorize. In addition to the foregoing requirements,. Behavioral Health Services denials shall must be rendered by board‑certified or board‑eligible psychiatrists or by a clinician licensed with the same or similar specialty as the Behavioral Health Services being denied, except in cases of denials of service for psychological testing, which shall be rendered by a qualified psychologist. The Contractor shall assure that all Behavioral Health authorization and utilization management activities are in compliance with 42 U.S.C. § 1396u‑2(b)(8). Contractor must comply with the requirements for demonstrating parity for both cost sharing (co‑payments) and treatment limitations between mental health and substance use disorder and medical/surgical inpatient, outpatient and pharmacy benefits. The Contractor shall authorize PAS to meet XxxxxxxxxEnrollees’ needs for assistance with ADLs and IADLs. The Contractor may consider the Enrollee’s need for physical assistance as well as cueing or monitoring in order for the Enrollee to perform an ADL or IADL. Authorizations must consider the medical and independent living needs of the Enrollee.