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.

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.

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.