Common use of Without limiting Para Clause in Contracts

Without limiting Para. a. above of this Sec. 3, Ex. B, Part 2, Contractor’s Service Authorization Request policies and procedures must comply with all of the following and provide that: (1) Contractor shall implement mechanisms to ensure consistent application of review criteria for Service Authorization and Prior Authorization decisions, taking into account applicable clinical practice guidelines, and consults with the requesting Provider when appropriate; (2) Any and all decisions to deny a Service Authorization Request, or to authorize a service in an amount, duration, or scope that is less than requested, be made by a Health Care Professional who has appropriate clinical expertise in treating the Member’s physical, mental, Oral Health condition or disease, as applicable; (3) Contractor can require Members and Subcontractors to obtain Prior Authorization for Covered Services from Contractor provided that such Prior Authorization: (i) does not violate any Applicable Law, and (ii) is in accordance with 42 CFR § 438.210(4) and 42 CFR § 441.20 as follows: (a) the services supporting individuals with ongoing or (4) Consistent with OAR 000-000-0000, Members shall not be required to obtain Prior Approval or a Referral from a Primary Care Physician in order to gain access to Behavioral Health assessment and evaluation services, and Members may Refer themselves to Behavioral Health services available from the Provider Network; (5) Contractor shall not require, as set forth in OAR 000-000-0000,8 Members to obtain Prior Authorization for Medication-Assisted Treatment (“MAT”) from within Contractor’s Provider Network. However, Contractor may, but is not obligated to, require Members to obtain Prior Authorization for MAT as otherwise permitted under OAR 000-000-0000. Notwithstanding the requirement relating to Contractor’s Provider Network in this Sub.Para. (5), in the event a Member is unable to receive timely access to care as required under this Contract, such affected Member shall have the right to receive the same treatment as set forth herein from a Non-Participating Provider outside of or within Contractor’s Service Area. The rights of Members under this Sub.Para. (5), Para. b, Sec. 3 of this Ex. B, Part 2 shall apply to each episode of care; (6) Members shall have the right to obtain certain Behavioral Health services from within Contractor’s Provider Network without Prior Authorization as specified in OAR 410- 141-3835, except that Contractor shall require Prior Authorization for applied behavior analysis (ABA), electroconvulsive therapy (ECT), neuropsychological evaluations, and transcranial magnetic stimulation (TMS). (7) Members shall have the right to refer themselves to: (a) A Traditional Health Worker for services within the scope of practice defined in Oregon Administrative Rules; and (b) Covered family planning services from out-of-network Providers as described in Ex. B, Part 2, Sec. 6, Para. b. (8) Members shall have the right to have a sexual abuse exam without Prior Authorization; (9) Pursuant to 42 CFR § 438.14(b)(4) and (6), Contractor shall permit (i) its Indian Members to obtain Covered Services from Non-Participating IHCPs from whom the Indian Members are otherwise eligible to receive services; and (ii) Non-Participating IHCPs to refer Indian Members to Participating Providers for Covered Services; (10) Contractor shall pay Indian Health Care Providers as specified in Ex. B, Pt. 8, Sec. 5, Para. g. OHA will provide Contractor with the IHS and Prospective Payment System (PPS) encounter rates for IHCPs upon request. Further, OHA will provide a Guidance Document to assist Contractor with complying with IHCP payment requirements, including information about which services are excluded from the IHS and PPS encounter rates. Contractor shall comply with all other applicable payment obligations relating to IHCPs as set forth in 25 USC § 1621e and 42 CFR § 438.14(b)(2) and (c); (11) In accordance with 42 CFR § 438.210(d)(1), Contractor shall provide notice to, in response to all standard Service Authorization Requests, the requesting Provider as expeditiously as the Member’s physical health, Oral Health, or Behavioral Health condition requires, not to exceed fourteen (14) calendar days following receipt of the request for service, with a possible extension of fourteen (14) additional calendar days if the Member or Provider requests an extension, or if Contractor justifies a need for additional information and can demonstrate that the extension is in the Member’s interest. In the event Contractor cannot meet the fourteen (14) day timeframe, Contractor may extend its time for decision by an additional fourteen (14) days subject to: (i) providing the affected Member and the Member’s Provider with written notice of the reason Contractor requires additional time and how such additional time is in the Member’s interest and (ii) informing the Member of the right to file a Grievance in accordance with Ex. I of this Contract if such Member disagrees with such request. Contractor shall issue and carry out its determination as expeditiously as the Member's health condition requires and no later than the date that the extension expires. In addition, when Contractor fails to provide notice of a decision regarding a Service Authorization Request within the timeframes specified in this Sub.Para. (11) of this Para. b, Sec. 3, Ex. B, Part 2, or if Contractor denies a Service Authorization Request, or decides to authorize a service in an amount, duration, or scope that is less than requested, Contractor shall issue a notice of Adverse Benefit Determination in accordance with Ex. I of this Contract. Upon request, Contractor shall also provide the information it provides to Members and Providers under this Sub.Para. (11), Sec. 3, Ex. B, Part 2, to OHA or its designee; (12) If a Member or Provider suggests, or Contractor determines, that following the standard timeframes could seriously jeopardize the Member’s life or health or ability to attain, maintain, or regain maximum function, Contractor shall make an expedited service authorization decision, and provide notice, as expeditiously as the Member’s health or Behavioral Health condition requires but in no event more than seventy-two (72) hours after receipt of the request for service. Contractor may extend the seventy-two (72) hour time period by up to fourteen (14) days if the Member requests an extension, or if Contractor justifies a need for additional information and demonstrates that the extension is in the Member’s interest. If Contractor denies an expedited Service Authorization Request under this Para. b of this Sec. 3, Ex. B, Part 2, or decides to authorize a service in an amount, duration, or scope that is less than requested, Contractor shall issue a notice of an Adverse Benefit Determination to the Provider and Member, or Member Representative, consistent with Ex. I, Grievance and Appeal System; (13) For all covered Outpatient drug authorization decisions, Contractor shall provide a response as described in section 1927(d)(5)(A) of the Act and 42 USC 1396r–8(d)(5)(A) and OAR 000-000-0000; (14) Contractor shall not have the right to restrict coverage for any Hospital length of stay following a normal vaginal birth to less than forty-eight (48) hours, or less than ninety-six

Without limiting Para. a. above of this Sec. 3, Ex. B, Part 2, Contractor’s Service Authorization Request policies and procedures must comply with all of the following and provide that: (1) Contractor shall implement mechanisms to ensure consistent application of review criteria for Service Authorization and Prior Authorization decisions, taking into account applicable clinical practice guidelines, and consults with the requesting Provider when appropriate; (2) Any and all decisions to deny a Service Authorization Request, or to authorize a service in an amount, duration, or scope that is less than requested, be made by a Health Care Professional who has appropriate clinical expertise in treating the Member’s physical, mental, Oral Health condition condition, or disease, as applicable; (3) Contractor can require Members and Subcontractors to obtain Prior Authorization for Covered Services from Contractor provided that such Prior Authorizationthat: (i) such Prior Authorization does not violate any Applicable Lawlaw, and (ii) is in accordance with 42 41 CFR § §438.210(4) and 42 CFR § 441.20 as follows: (a) the services supporting individuals with ongoing orCFR (4) Consistent with OAR 000-000-0000, Members shall not be required to obtain Prior Approval or a Referral from a Primary Care Physician in order to gain access to Behavioral Health assessment and evaluation services, and . Members may Refer themselves to Behavioral Health services available from the Provider Network; (5) Contractor shall not require, as set forth in OAR 000-000-0000,8 Members to obtain Prior Authorization for Medication-Assisted Treatment (“MAT”) from within Contractor’s Provider Network. However, Contractor may, but is not obligated to, require Members to obtain Prior Authorization for MAT as otherwise permitted under OAR 000-000-0000. Notwithstanding the requirement relating to Contractor’s Provider Network in this Sub.Para. (5), in the event a Member is unable to receive timely access to care as required under this Contract, such affected Member shall have the right to receive the same treatment as set forth herein from a Non-Participating Provider outside of or within Contractor’s Service Area. The rights of Members under this Sub.Para. (5), Para. b, Sec. 3 of this Ex. B, Part 2 shall apply to each episode of care; (6) Members shall have the right to obtain certain Behavioral Health services from within Contractor’s Provider Network without Prior Authorization as specified in OAR 410- 141-3835, except that Contractor shall require Prior Authorization for applied behavior analysis (ABA), electroconvulsive therapy (ECT), neuropsychological evaluations, and transcranial magnetic stimulation (TMS). (7) Members shall have the right to refer themselves to: (a) A to a Traditional Health Worker for services within the scope of practice defined in Oregon Administrative Rules; and; (b6) Covered family planning services from out-of-network Providers as described in Ex. B, Part 2, Sec. 6, Para. b. (8) Members shall have the right to have a sexual abuse exam without Prior Authorization;. (97) Pursuant to 42 CFR § 438.14(b)(4) and (6), Contractor shall must permit (i) its Indian Members to obtain Covered Services from Non-Non- Participating IHCPs from whom the Indian Members are otherwise eligible Providers, and be referred to receive services; and (ii) Non-a Participating IHCPs to refer Indian Members to Participating Providers Provider for Covered Services; (10) Contractor shall pay Indian Health Care Providers as specified Services by, IHCPs in Ex. B, Pt. 8, Sec. 5, Para. g. OHA will provide Contractor accordance with the IHS and Prospective Payment System (PPS) encounter rates for IHCPs upon request. Further, OHA will provide a Guidance Document to assist Contractor with complying with IHCP payment requirements, including information about which services are excluded from the IHS and PPS encounter rates. Contractor shall comply with all other applicable payment obligations relating to IHCPs as set forth in 25 USC § 1621e and 42 CFR § 438.14(b)(2§438.14(b)(4) and (c6); (11) 8) In accordance with 42 CFR § §438.210(d)(1), Contractor shall provide notice to, in response to all standard Service Authorization Requests, the requesting Provider as expeditiously as the Member’s physical health, Oral Health, health or Behavioral Health condition requires, not to exceed fourteen (14) calendar days following receipt of the request for service, with a possible extension of fourteen (14) additional calendar days if the Member or Provider requests an extension, or if the Contractor justifies a need for additional information and can demonstrate that the extension is in the Member’s interest. In the event Contractor cannot meet the fourteen (14) day timeframe, Contractor may extend its time for decision by an additional fourteen (14) days subject to: accordance with 42 CFR (i) providing the affected effected Member and the Member’s Provider with written notice of the reason Contractor it requires additional time and time, (ii) how such additional time is in the Member’s interest best interest, and (iiiii) informing and inform the Member of the right to file a Grievance in accordance with Ex. I of this Contract if such Member disagrees with such request. Contractor shall issue and carry out its determination as expeditiously as the Member's health condition requires and no later than the date that the extension expires. In addition, when Contractor fails to provide notice of a decision regarding a Service Authorization Request within the timeframes specified in this Sub.. Para. (11) 8) of this Para. b, Sec. 3, Ex. B, Part 2, or if Contractor denies a Service Authorization Request, or decides to authorize a service in an amount, duration, or scope that is less than requested, the Contractor shall issue a notice of Adverse Benefit Determination in accordance with Ex. Exhibit I of this Contract. Upon request, Contractor shall must also provide the information it provides to Members and Providers under this Sub.. Para. (11)8), Sec. 3, Ex. B, Part 2, 2 to OHA or its designeedesignee upon request; (129) If a Member or Provider suggests, or Contractor determines, that following the standard timeframes could seriously jeopardize the Member’s life or health or ability to attain, maintain, or regain maximum function, Contractor shall make an expedited service authorization decision, and provide notice, as expeditiously as the Member’s health or Behavioral Health mental health condition requires but in and no event more later than seventy-two (72) 72 hours after receipt of the request for service. Contractor may extend the seventy-two (72) 72 hour time period by up to fourteen (14) 14 days if the Member requests an extension, or if Contractor justifies a need for additional information and demonstrates that the extension is in the Member’s interest. If Contractor denies an expedited Service Authorization Request service authorization request under this Para. b of this Sec. 3, Ex. B, Part 2, or decides to authorize a service in an amount, duration, or scope that is less than requested, the Contractor shall issue a notice of an Adverse Benefit Determination to the Provider and Member, or Member Representative, consistent with Ex. Exhibit I, Grievance and Appeal System; (1310) For all covered Outpatient outpatient drug authorization decisions, Contractor shall must provide a response as described in section 1927(d)(5)(A) of the Act and 42 USC 1396r–8(d)(5)(A) and OAR 000410-000141-00003225; (1411) Contractor shall not have the right to restrict coverage for any Hospital length of stay following a normal vaginal birth to less than forty-eight (48) 48 hours, or less than ninety96 hours for a cesarean section. An exception to the minimum length of stay may be made by the Physician in consultation with the mother, which must be documented in the Clinical Record; (12) Contractor shall ensure that Dental Services that must be performed in an outpatient Hospital ASC, due to the age, disability, or medical condition of the Member, are coordinated and preauthorized; (13) Contractor shall not have the right, except as permitted under Sub. Para. (12) of this Para. b, Ex. B, Part 2 of this Contract, to prohibit or otherwise limit or restrict Health Care Professionals who are its employees, or Subcontractors acting within the lawful scope of practice, from undertaking any of the activities set forth below in this Sub. Para. (13), Para. b, Ex. B, Part 2 of this Contract, on behalf of Members who are patients of such Health Care Professionals: (a) Advising or otherwise advocating for aMember’s health status, medical care, or treatment options, including any alternative treatment that may be self- administered, that is Medically Appropriate even if such care or treatment is not covered under this Contract or is subject to Co-sixPayment; (b) Providing any and all information a Member needs in order to decide among relevant treatment options; (c) Advising a Member of the risks, benefits, and consequences of treatment or non- treatment; and (d) Xxxxxxxx and advocating for a Member’s right to participate in decisions regarding the Member’s own health care, including the right to refuse treatment, and to express preferences about future treatment decisions. (14) Contractor shall provide written notification to the requesting Provider when Contractor denies a request for authorization of a Covered Service or when Contractor approves a Service Authorization Request but such approval is for an amount, duration, or scope that is less than requested; and (15) Contractor shall provide written notification to the affected Member when Contractor denies a Service Authorization Request, or approves a Service Authorization Request but such approval is for an amount, duration or scope that is less than requested. Such written notification must be made in accordance the requirements of Exhibit I.

Without limiting Para. a. above of this Sec. 3, Ex. B, Part 2, Contractor’s Service Authorization Request policies and procedures must comply with all of the following and provide that: (1) Contractor shall implement mechanisms to ensure consistent application of review criteria for Service Authorization and Prior Authorization decisions, taking into account applicable clinical practice guidelines, and consults with the requesting Provider when appropriate; (2) Any and all decisions to deny a Service Authorization Request, or to authorize a service in an amount, duration, or scope that is less than requested, be made by a Health Care Professional who has appropriate clinical expertise in treating the Member’s physical, mental, Oral Health condition or disease, as applicable; (3) Contractor can require Members and Subcontractors to obtain Prior Authorization for Covered Services from Contractor provided that such Prior Authorization: (i) does not violate any Applicable Law, and (ii) is in accordance with 42 CFR § 438.210(4) and 42 CFR § 441.20 as follows: (a) the services supporting individuals with ongoing oror chronic conditions, or those who require Long Term Services and Supports are authorized in a manner that reflects the Member’s ongoing need for such services, (b) without limiting a Member’s rights under Para. b, Sec. 6 of this Ex, B, Part 2 of the Contract, family planning services are provided in a manner that protects and enables a (4) Consistent with OAR 000-000-0000, Members shall not be required to obtain Prior Approval or a Referral from a Primary Care Physician in order to gain access to Behavioral Health assessment and evaluation services, and Members may Refer themselves to Behavioral Health services available from the Provider Network; (5) Members shall have the right to obtain Contractor shall not require, as set forth in OAR 000-000-0000,8 Members to obtain Prior Authorization for Medication-Assisted Treatment (“MAT”) from within Contractor’s Provider NetworkNetwork without Prior Authorization the first thirty (30) days of treatment as specified in OAR 410-141- 3835. However, Contractor may, but is not obligated to, require Members to obtain Prior Authorization for MAT as otherwise permitted under OAR 000-000-0000. Notwithstanding the requirement relating to Contractor’s Provider Network in this Sub.Para. (5), In in the event a Member is unable to receive timely access to care as required under this Contract, such affected Member shall have the right to receive the same treatment as set forth herein from a Non-Participating Provider outside of or within Contractor’s Service Area. The rights of Members under this Sub.. Para. (5), Para. b, Sec. 3 of this Ex. B, Part 2 shall apply to each episode of care; (6) Members shall have the right to obtain certain Behavioral Health services from within Contractor’s Provider Network without Prior Authorization as specified in OAR 410- 141-3835, except that Contractor shall require Prior Authorization for applied behavior analysis (ABA), electroconvulsive therapy (ECT), neuropsychological evaluations, and transcranial magnetic stimulation (TMS). (7) Members shall have the right to refer themselves to: (a) A Traditional Health Worker for services within the scope of practice defined in Oregon Administrative Rules; and (b) Covered family planning services from out-of-network Providers as described in Ex. B, Part 2, Sec. 6, Para. b. (8) Members shall have the right to have a sexual abuse exam without Prior Authorization; (9) Pursuant to 42 CFR § 438.14(b)(4) and (6), Contractor shall permit (i) its Indian Members to obtain Covered Services from Non-Participating IHCPs from whom the Indian Members are otherwise eligible to receive services; and (ii) Non-Participating IHCPs to refer Indian Members to Participating Providers for Covered Services; (10) Contractor shall pay Indian Health Care Providers as specified in Ex. B, Pt. 8, Sec. 5, Para. g. OHA will provide Contractor with the IHS and Prospective Payment System (PPS) encounter rates for IHCPs upon request. Further, OHA will provide a Guidance Document to assist Contractor with complying with IHCP payment requirements, including information about which services are excluded from the IHS and PPS encounter rates. Contractor shall comply with all other applicable payment obligations relating to IHCPs as set forth in 25 USC § 1621e and 42 CFR § 438.14(b)(2) and (c); (11) In accordance with 42 CFR § 438.210(d)(1), Contractor shall provide notice to, in response to all standard Service Authorization Requests, the requesting Provider as expeditiously as the Member’s physical health, Oral Health, or Behavioral Health condition requires, not to exceed fourteen (14) calendar days following receipt of the request for service, with a possible extension of fourteen (14) additional calendar days if the Member or Provider requests an extension, or if Contractor justifies a need for additional information and can demonstrate that the extension is in the Member’s interest. In the event Contractor cannot meet the fourteen (14) day timeframe, Contractor may extend its time for decision by an additional fourteen (14) days subject to: (i) providing the affected Member and the Member’s Provider with written notice of the reason Contractor requires additional time and how such additional time is in the Member’s interest and (ii) informing the Member of the right to file a Grievance in accordance with Ex. I of this Contract if such Member disagrees with such request. Contractor shall issue and carry out its determination as expeditiously as the Member's health condition requires and no later than the date that the extension expires. In addition, when Contractor fails to provide notice of a decision regarding a Service Authorization Request within the timeframes specified in this Sub.Para. (11) of this Para. b, Sec. 3, Ex. B, Part 2, or if Contractor denies a Service Authorization Request, or decides to authorize a service in an amount, duration, or scope that is less than requested, Contractor shall issue a notice of Adverse Benefit Determination in accordance with Ex. I of this Contract. Upon request, Contractor shall also provide the information it provides to Members and Providers under this Sub.Para. (11), Sec. 3, Ex. B, Part 2, to OHA or its designee; (12) If a Member or Provider suggests, or Contractor determines, that following the standard timeframes could seriously jeopardize the Member’s life or health or ability to attain, maintain, or regain maximum function, Contractor shall make an expedited service authorization decision, and provide notice, as expeditiously as the Member’s health or Behavioral Health condition requires but in no event more than seventy-two (72) hours after receipt of the request for service. Contractor may extend the seventy-two (72) hour time period by up to fourteen (14) days if the Member requests an extension, or if Contractor justifies a need for additional information and demonstrates that the extension is in the Member’s interest. If Contractor denies an expedited service Service authorization Authorization request Request under this Para. b of this Sec. 3, Ex. B, Part 2, or decides to authorize a service in an amount, duration, or scope that is less than requested, Contractor shall issue a notice of an Adverse Benefit Determination to the Provider and Member, or Member Representative, consistent with Ex. I, Grievance and Appeal System; (13) For all covered Outpatient drug authorization decisions, Contractor shall provide a response as described in section 1927(d)(5)(A) of the Act and 42 USC 1396r–8(d)(5)(A) and OAR 000-000-0000; (14) Contractor shall not have the right to restrict coverage for any Hospital length of stay following a normal vaginal birth to less than forty-eight (48) hours, or less than ninety-six

Without limiting Para. a. above of this Sec. 3, Ex. B, Part 2, Contractor’s Service Authorization Request policies and procedures must comply with all of the following and provide that: (1) Contractor shall implement mechanisms to ensure consistent application of review criteria for Service Authorization and Prior Authorization decisions, taking into account applicable clinical practice guidelines, and consults with the requesting Provider when appropriate; (2) Any and all decisions to deny a Service Authorization Request, or to authorize a service in an amount, duration, or scope that is less than requested, be made by a Health Care Professional who has appropriate clinical expertise in treating the Member’s physical, mental, Oral Health condition condition, or disease, as applicable; (3) Contractor can require Members and Subcontractors to obtain Prior Authorization for Covered Services from Contractor provided that such Prior Authorization: (i) does not violate any Applicable Law, and (ii) is in accordance with 42 CFR § 438.210(4) and 42 CFR § 441.20 as follows: (a) the services supporting individuals with ongoing oror chronic conditions, or those who require Long Term Services and Supports are authorized in a manner that reflects the Member’s ongoing need for such services, (b) without limiting a Member’s rights under Para. b, Sec. 6 of this Ex, B, Part 2 of the Contract, family planning services are provided in a manner that protects and enables a Member’s freedom to choose a method of family planning, and (c) the services furnished are sufficient in amount, duration, and scope as necessary to achieve, as reasonably expected, the purpose for which the services are furnished; (4) Consistent with OAR 000-000-0000, Members shall not be required to obtain Prior Approval or a Referral from a Primary Care Physician in order to gain access to Behavioral Health assessment and evaluation services, and . Members may Refer themselves to Behavioral Health services available from the Provider Network; (5) Contractor shall not require, as set forth in OAR 000-000-0000,8 Members to obtain Prior Authorization for Medication-Assisted Treatment (“MAT”) from within Contractor’s Provider Network. However, Contractor may, but is not obligated to, require Members to obtain Prior Authorization for MAT as otherwise permitted under OAR 000-000-0000. Notwithstanding the requirement relating to Contractor’s Provider Network in this Sub.Para. (5), in the event a Member is unable to receive timely access to care as required under this Contract, such affected Member shall have the right to receive the same treatment as set forth herein from a Non-Participating Provider outside of or within Contractor’s Service Area. The rights of Members under this Sub.Para. (5), Para. b, Sec. 3 of this Ex. B, Part 2 shall apply to each episode of care; (6) Members shall have the right to obtain certain Behavioral Health services from within Contractor’s Provider Network without Prior Authorization as specified in OAR 410- 141-3835, except that Contractor shall require Prior Authorization for applied behavior analysis (ABA), electroconvulsive therapy (ECT), neuropsychological evaluations, and transcranial magnetic stimulation (TMS). (7) Members shall have the right to refer themselves to: (a) A Traditional Health Worker for services within the scope of practice defined in Oregon Administrative Rules; and (b) Covered family planning services from out-of-network Providers as described in Ex. B, Part 2, Sec. 6, Para. b. (8) Members shall have the right to have a sexual abuse exam without Prior Authorization; (9) Pursuant to 42 CFR § 438.14(b)(4) and (6), Contractor shall permit (i) its Indian Members to obtain Covered Services from Non-Participating IHCPs from whom the Indian Members are otherwise eligible to receive services; and (ii) Non-Participating IHCPs to refer Indian Members to Participating Providers for Covered Services; (10) Contractor shall pay Indian Health Care Providers as specified in Ex. B, Pt. 8, Sec. 5, Para. g. OHA will provide Contractor with the IHS and Prospective Payment System (PPS) encounter rates for IHCPs upon request. Further, OHA will provide a Guidance Document to assist Contractor with complying with IHCP payment requirements, including information about which services are excluded from the IHS and PPS encounter rates. Contractor shall comply with all other applicable payment obligations relating to IHCPs as set forth in 25 USC § 1621e and 42 CFR § 438.14(b)(2) and (c); (11) In accordance with 42 CFR § 438.210(d)(1), Contractor shall provide notice to, in response to all standard Service Authorization Requests, the requesting Provider as expeditiously as the Member’s physical health, Oral Health, or Behavioral Health condition requires, not to exceed fourteen (14) calendar days following receipt of the request for service, with a possible extension of fourteen (14) additional calendar days if the Member or Provider requests an extension, or if Contractor justifies a need for additional information and can demonstrate that the extension is in the Member’s interest. In the event Contractor cannot meet the fourteen (14) day timeframe, Contractor may extend its time for decision by an additional fourteen (14) days subject to: (i) providing the affected Member and the Member’s Provider with written notice of the reason Contractor requires additional time and how such additional time is in the Member’s interest and (ii) informing the Member of the right to file a Grievance in accordance with Ex. I of this Contract if such Member disagrees with such request. Contractor shall issue and carry out its determination as expeditiously as the Member's health condition requires and no later than the date that the extension expires. In addition, when Contractor fails to provide notice of a decision regarding a Service Authorization Request within the timeframes specified in this Sub.Para. (11) of this Para. b, Sec. 3, Ex. B, Part 2, or if Contractor denies a Service Authorization Request, or decides to authorize a service in an amount, duration, or scope that is less than requested, Contractor shall issue a notice of Adverse Benefit Determination in accordance with Ex. I of this Contract. Upon request, Contractor shall also provide the information it provides to Members and Providers under this Sub.Para. (11), Sec. 3, Ex. B, Part 2, to OHA or its designee; (12) If a Member or Provider suggests, or Contractor determines, that following the standard timeframes could seriously jeopardize the Member’s life or health or ability to attain, maintain, or regain maximum function, Contractor shall make an expedited service authorization decision, and provide notice, as expeditiously as the Member’s health or Behavioral Health condition requires but in no event more than seventy-two (72) hours after receipt of the request for service. Contractor may extend the seventy-two (72) hour time period by up to fourteen (14) days if the Member requests an extension, or if Contractor justifies a need for additional information and demonstrates that the extension is in the Member’s interest. If Contractor denies an expedited Service Authorization Request under this Para. b of this Sec. 3, Ex. B, Part 2, or decides to authorize a service in an amount, duration, or scope that is less than requested, Contractor shall issue a notice of an Adverse Benefit Determination to the Provider and Member, or Member Representative, consistent with Ex. I, Grievance and Appeal System; (13) For all covered Outpatient drug authorization decisions, Contractor shall provide a response as described in section 1927(d)(5)(A) of the Act and 42 USC 1396r–8(d)(5)(A) and OAR 000-000-0000; (14) Contractor shall not have the right to restrict coverage for any Hospital length of stay following a normal vaginal birth to less than forty-eight (48) hours, or less than ninety-six