Services Requiring Prior Authorization Clause Samples
Services Requiring Prior Authorization. Please refer to Attachment B, Services Requiring Prior Authorization. The list represents services that are commonly reviewed and may require additional clinical information in order for a determination of Prior Authorization to be made. SHL recommends that the Insured or the Insured’s Physician or practitioner making a specific request for services verify benefits under this Plan and the Prior Authorization requirements prior to providing services. The Attachment B, Services Requiring Prior Authorization list is subject to change periodically and may be modified at any time without notification.
Services Requiring Prior Authorization. The Contractor shall provide, or arrange for the provision of, Covered Services as expeditiously as the Enrollee's health condition requires. Ordinarily, Covered Services shall be provided within fourteen (14) calendar days after receiving the request for service from a Provider, with a possible extension of up to fourteen (14) calendar days, if the Enrollee requests the extension or the Contractor provides written justification to the Department that there is a need for additional information and the Enrollee will not be harmed by the extension. If the Physician indicates, or the Contractor determines that following the ordinary time frame could seriously jeopardize the Enrollee's life or health, the Contractor shall provide, or arrange for the provision of, the Covered Service no later than seventy-two (72) hours after receipt of the request for service, with a possible extension of up to fourteen (14) calendar days, if the Enrollee requests the extension or the Contractor provides written justification to the Department that there is a need for additional information and the Enrollee will not be harmed by the extension.
Services Requiring Prior Authorization. All Covered Services not provided by the Member's Primary Care Provider (PCP) require Prior Authorization from the PCP and HPN’s Managed Care Program. The following Covered Services require Prior Authorization and review through HPN’s Managed Care Program: Non-emergency Inpatient admissions and extensions of stay in a Hospital, Skilled Nursing Facility, Residential Treatment Center or Hospice. Outpatient surgery provided in any setting, including technical and professional services.
Services Requiring Prior Authorization. All Covered Services not provided by the Member's PCP require written Prior Authorization from the PCP and HPN’s Managed Care Program. The following Covered Services require Prior Authorization and review through HPN’s Managed Care Program. Non-emergency Inpatient admissions and extensions of stay beyond the original certified length of stay in a Hospital, Skilled Nursing Facility or Hospice. All outpatient surgery provided in any setting, including technical and professional services. Diagnostic and Therapeutic Services. Home Healthcare Services. Severe Mental Illness, Mental Health and Substance Abuse Services. All Specialist visits or consultations. Prosthetic Devices and Orthotic Devices. Courses of treatment, including but not limited to allergy testing or treatment (e.g., skin, RAST); angioplasty; anti-cancer drug therapy; dialysis; physiotherapy or Manual Manipulation; or rehabilitation therapy (physical, speech, occupational).
Services Requiring Prior Authorization. Contractor shall authorize or deny Covered Services, including pharmacy services, that require prior authorization as expeditiously as the Enrollee’s health condition requires. Ordinarily, requests for authorizations shall be reviewed and decided within ten (10) days after receiving the request for authorization from a Provider, with a possible extension of up to ten (10) additional days, if the Enrollee requests the extension or Contractor informs the Provider that there is a need for additional written justification demonstrating that the Covered Service is Medically Necessary and the Enrollee will not be harmed by the extension. If the Physician indicates, or Contractor determines, that following the ordinary review and decision time frame could seriously jeopardize the Enrollee’s life or health, Contractor shall authorize or deny the Covered Service no later than twenty-four (24) hours after receipt of the request for authorization for pharmacy services and no later than seventy-two (72) hours after receipt of the request for authorization.
Services Requiring Prior Authorization. Contractor shall authorize or deny Covered Services that require prior authorization, including pharmacy services, as expeditiously as the Enrollee’s health condition requires. Ordinarily, requests for authorizations shall be reviewed and decided on within seventy‐two (72) hours after receiving the request for authorization from a Provider, with a possible extension of up to seventy‐two (72) additional hours, if the Enrollee requests the extension or Contractor informs the Provider that there is a need for additional written justification demonstrating that the Covered Service is Medically Necessary and the Enrollee will not be harmed by the extension. If the Provider indicates, or Contractor determines, that following the ordinary review and decision time frame could seriously jeopardize the Enrollee’s life or health, Contractor shall authorize or deny the Covered Service no later than forty‐eight (48) hours after receipt of the request for authorization. Contractor shall authorize or deny a prior authorization request for pharmacy services no later than twenty‐four (24) hours after receipt of the request for authorization.
5.19.7.1 Contractor shall authorize services supporting individuals with ongoing or chronic conditions, or who require LTSS, in a manner that reflects the Enrollee’s ongoing need for such services.
5.19.7.2 For all covered outpatient drug authorization decisions, Contractor shall provide notice as described in Section 1927(d)(5)(A) of the SSA.
Services Requiring Prior Authorization. The final decision as to whether any care should be received is between the Insured and the Provider. If SHL denies a request by an Insured and/or Provider for Prior Authorization of a service, the Insured or his Authorized Representative may appeal the denial to the Grievance Review Committee (see the Appeals Procedures Section).