Services Requiring Prior Authorization Sample Clauses

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.
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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.
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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.
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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).
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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.
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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.
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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).
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Related to Services Requiring Prior Authorization

  • Prior Authorization A determination to authorize a Provider’s request, pursuant to services covered in the MississippiCAN Program, to provide a service or course of treatment of a specific duration and scope to a Member prior to the initiation or continuation of the service.

  • WORK AUTHORIZATIONS The State will issue work authorizations using the form included in Attachment D (Work Authorizations and Supplemental Work Authorizations) to authorize all work under this contract. The Engineer must sign and return a work authorization within seven (7) working days after receipt. Refusal to accept a work authorization may be grounds for termination of the contract. The State shall not be responsible for actions by the Engineer or any costs incurred by the Engineer relating to work not directly associated with or prior to the execution of a work authorization. Terms and conditions governing the use of work authorizations are set forth in Attachment A, General Provisions, Article 1.

  • Suspension of Work Authorization DocuSign Envelope ID: F977C999-9391-4B1E-8882-3E74EBE07795

  • Work Authorization By entering into this Agreement, the Judicial Council only authorizes the Criteria Architect to begin its Work on the Phase indicated on the Coversheet of the Agreement. The Judicial Council has the sole and unilateral right to authorize additional Phases, however, those authorizations will be made in the form of an amendment pursuant to this Agreement, authorizing the appropriate Phase and funding specified herein, which must be executed by the Criteria Architect and the Judicial Council. Work for additional Phases added to the Agreement by amendment will be authorized using Notice to Proceed. Criteria Architect is not authorized to begin any work or services marked “NYA” (Not Yet Authorized).

  • Power; Authorization Such Investor has all requisite power and authority to execute and deliver this Agreement. This Agreement, when executed and delivered by such Investor, will constitute a valid and legally binding obligation of such Investor, enforceable in accordance with its respective terms, except as: (a) limited by applicable bankruptcy, insolvency, reorganization, moratorium and other laws of general application affecting enforcement of creditors’ rights generally; and (b) limited by laws relating to the availability of specific performance, injunctive relief or other equitable remedies.

  • New Work Authorization If the Engineer does not complete the services authorized in a work authorization before the specified completion date and has not requested a supplemental work authorization, the work authorization shall terminate on the completion date. At the sole discretion of the State, it may issue a new work authorization to the Engineer for the incomplete work using the unexpended balance of the preceding work authorization for the project. If approved by the State, the Engineer may calculate any additional cost for the incomplete work using the rates set forth in the preceding work authorization and in accordance with Attachment E, Fee Schedule.

  • Emergency Work Authorizations The State, at its sole discretion, may accept the Engineer's signature on a faxed copy of the work authorization as satisfying the requirements for executing the work authorization, provided that the signed original is received by the State within five business days from the date on the faxed copy.

  • Supplemental Work Authorizations Before additional work may be performed or additional costs incurred, a change in a work authorization shall be enacted by a written supplemental work authorization in the form identified and attached hereto as Attachment D. Both parties must execute a supplemental work authorization within the period of performance specified in the work authorization. The State shall not be responsible for actions by the Engineer or any costs incurred by the Engineer relating to additional work not directly associated with the performance or prior to the execution of the work authorization. The Engineer shall allow adequate time for review and approval of the supplemental work authorization by the State prior to expiration of the work authorization. Any supplemental work authorization must be executed by both parties within the time period established in Article 2 of the contract, (Contract Period). Under no circumstances will a work authorization be allowed to extend beyond the contract's expiration date or will the total amount of funds exceed the maximum amount payable set forth in Article 3A of the contract (Compensation).

  • Governmental Authorization; Third Party Consents No approval, consent, compliance, exemption or authorization of any governmental authority or agency, or of any other person or entity, is necessary or required in connection with the execution, delivery or performance by, or enforcement against, the Warrant Holder of this Warrant Agreement or the transactions contemplated hereby.

  • No Further Authorizations or Approvals Required The Company’s execution, delivery and performance of this Agreement, the issuance and sale of the Securities, the compliance by the Company with all of the provisions of the Securities, the Indenture and consummation of the transactions contemplated hereby and thereby and by the Registration Statement, the Prospectus and the Pricing Disclosure Package (i) have been duly authorized by all necessary corporate action, have been effected in accordance with the 1940 Act and will not result in any violation of the provisions of the charter, articles or certificate of incorporation or by-laws of the Company or similar organizational documents of any subsidiary, (ii) will not conflict with or constitute a breach of, or default under, or result in the creation or imposition of any lien, charge or encumbrance upon any property or assets of the Company or any of its subsidiaries pursuant to, or require the consent of any other party to, any existing instrument, except for such conflicts, breaches, defaults, liens, charges or encumbrances as would not, individually or in the aggregate, result in a Material Adverse Effect, (iii) will not result in any material respect in any violation of any law, administrative regulation or administrative or court decree applicable to the Company or any subsidiary and (iv) will not affect the validity of the Securities or the legal authority of the Company to comply with the Securities, the Indenture or this Agreement. No consent, approval, authorization or other order of, or registration or filing with, any court or other governmental or regulatory authority or agency, is required for the Company’s execution, delivery and performance of this Agreement, the compliance by the Company with all of the provisions of the Securities, the Indenture or consummation of the transactions contemplated hereby and thereby and by the Registration Statement, the Prospectus and the Pricing Disclosure Package, except such as have already been obtained or made under the 1933 Act, the 1940 Act and the Trust Indenture Act and such as may be required under any applicable state securities or blue sky laws or from the Financial Industry Regulatory Authority, Inc. (“FINRA”).

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