Utilization Management Programs. The MCP shall implement clearly defined structures and processes to maximize the effectiveness of the care provided to members pursuant to OAC rule 5160-26-03.1. Pursuant to the criteria in ORC section 5160.34(C), the MCP is prohibited from retroactively denying a prior authorization (PA) request as a utilization management strategy. In addition, the MCP shall permit the retrospective review of a claim submitted for a service where PA was required, but not obtained, pursuant to the criteria in ORC section 5160.34(B)(9). Also ORC section 5160.34 requires the MCPs establish a streamlined provider appeal process relating to adverse PA determinations.
Appears in 4 contracts
Samples: Provider Agreement, Provider Agreement, Provider Agreement
Utilization Management Programs. The MCP shall implement clearly defined structures and processes to maximize the effectiveness of the care provided to members pursuant to OAC rule 5160-26-03.1. .
a. Pursuant to the criteria in ORC section 5160.34(C), the MCP is prohibited from retroactively denying a prior authorization (PA) request as a utilization management strategy. In addition, the MCP shall permit the retrospective review of a claim submitted for a service where PA was required, but not obtained, pursuant to the criteria in ORC section 5160.34(B)(9). Also Also, ORC section 5160.34 requires the MCPs establish a streamlined provider appeal process relating to adverse PA determinations.
Appears in 3 contracts
Samples: Provider Agreement, Provider Agreement, Provider Agreement
