Common use of Services Requiring Prior Authorization Clause in Contracts

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. 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 seventy-two (72) hours after receiving the request for authorization from a Provider, with a possible extension of up to seventy‐two 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 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 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. 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 four (724) hours days after receiving the request for authorization from a Provider, with a possible extension of up to seventy‐two four (724) additional hoursdays, 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 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 twenty-four (24) hours after receipt of the request for authorization. 5.19.7.1 5.19.8.1 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 5.19.8.2 For all covered outpatient drug authorization decisions, Contractor shall provide notice as described in Section 1927(d)(5)(A) of the SSA. 5.19.8.3 For authorizations for MLTSS Enrollees residing in a NF, if a response to the authorization is not provided within twenty-four (24) hours of the request and the NF is required by regulation to provide a service because a Physician ordered it, the Contractor must pay for the service if it is a Covered Service, provided that the request is consistent with the policies and procedures of the Contractor.‌