Common use of Timing of Notification of Benefit Determination Clause in Contracts

Timing of Notification of Benefit Determination. All requests for Prior Authorization must be initiated by the Member’s Physician. If a Physician or Member fails to follow the Plan’s procedures for filing a request for Prior Authorization (Pre-Service Claim), the Member shall be notified of the failure and the proper procedures to be followed in order to obtain Prior Authorization provided the Member’s request for Prior Authorization is received by an employee or department of the Plan customarily responsible for handling benefit matters and the original request specifically named the Member, a specific medical condition or symptom, and a specific treatment, service or product for which approval is requested. The Member notification of correct Prior Authorization procedures from the Plan shall be provided as soon as possible, but not later than five (5) days (twenty-four (24) hours in the case of an Urgent Care Claim) following the Plan’s receipt of the Member’s original request. Notification by HPN may be oral unless specifically requested in writing by the Member.