Common use of Services Requiring Prior Authorization Clause in Contracts

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, including pharmacy services, that which 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 authorizationauthorization for all other covered services.

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.