Failure to Obtain Prior Authorization Clause Samples
The "Failure to Obtain Prior Authorization" clause establishes the requirement for a party, typically a service provider or insured individual, to secure approval from a designated authority before proceeding with certain actions or incurring specific expenses. In practice, this often applies to healthcare services, where a patient or provider must receive authorization from an insurance company before undergoing particular treatments or procedures. If prior authorization is not obtained, the responsible party may face denial of coverage or reimbursement, or may be liable for the costs themselves. This clause serves to control costs, manage risk, and ensure that only necessary or pre-approved actions are undertaken, thereby protecting the interests of the authorizing party.
Failure to Obtain Prior Authorization. If the Member, the Member’s provider, or other appropriate party, as identified above, does not obtain Prior Authorization, The Plan will conduct a retrospective review after the claims have been submitted. If it is determined that the services were not Medically Necessary, were Experimental/Investigational/Unproven, were not performed in the appropriate treatment setting, or did not otherwise meet the terms and conditions of the Contract, the Member may be responsible for the full cost of the services. Length of Stay/Service Review Upon completion of the inpatient or emergency admission review, Blue Cross and Blue Shield of Montana will send a letter to the Member, the Member’s provider, behavioral health practitioner and/or Hospital or facility with a determination on the approved length of service or length of stay. An extension of the length of stay/service will be based solely on whether continued Inpatient Care or other health care services are Medically Necessary. If the extension is determined not to be Medically Necessary, the coverage for the length of stay/service will not be extended, except as otherwise described in the Appeal Procedure section of this Contract. A length of stay/service review, also known as a concurrent Medical Necessity review, occurs when the Member, the Member’s provider, or other authorized representative submits a request to The Plan for continued services. If the Member, the Member’s provider or authorized representative requests to extend care beyond the approved time limit and it is a request involving Urgent Care or an ongoing course of treatment, The Plan will make a determination on the request as soon as possible but no later than 48 hours after it receives an urgent request, within 48 hours after it receives requested information (if the initial request is incomplete), or within seven business days after receipt of a non-urgent concurrent request. Recommended Clinical Review A Recommended Clinical Review is a Medical Necessity review for a covered service that occurs before services are completed and helps limit the situations where the Member may have to pay for a non-approved service. The Plan will review a Clinical Review request to determine if it meets approved Blue Cross and Blue Shield of Montana Medical Policy and/or level of care review criteria for medical and behavioral health services. Once a decision has been made on the services reviewed as part of the Recommended Clinical Review process, the servic...
Failure to Obtain Prior Authorization. The Insured’s Physician must initiate all requests for Prior Authorization. If a Physician or Insured fails to follow the Plan’s procedures for filing a request for Prior Authorization (Pre-Service Claim), the Insured shall be notified of the failure and the proper procedures to be followed in order to obtain Prior Authorization. The Insured’s request for Prior Authorization must be received by an employee or by the department of the Plan customarily responsible for handling benefit matters. The original request must specifically name the Insured, the specific medical condition or symptom and the specific treatment, service or product for which approval is requested. The Insured 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 Insured’s original request. Notification by SHL may be oral unless specifically requested in writing by the Insured.
Failure to Obtain Prior Authorization. The Member’s Physician must initiate all requests for Prior Authorization. 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. The Member’s request for Prior Authorization must be received by an employee or by the department of the Plan customarily responsible for handling benefit matters. The original request must specifically name the Member, the specific medical condition or symptom and the 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.
Failure to Obtain Prior Authorization. If an Insured fails to follow the Plan’s procedures for filing a request for Prior Authorization (Pre-Service Claim), the Insured shall be notified of the failure and the proper procedures to be followed in order to obtain Prior Authorization provided the Insured’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 Insured, a specific medical condition or symptom, and a specific treatment, service or product for which approval is requested. The Insured notification of correct Prior Authorization procedures from the Plan shall be provided as soon as possible, but not later than five (5) days (twenty- Form No. SHL-Ind_AOC(2015) Page 25 four (24) hours in the case of an Urgent Care Claim) following the Plan’s receipt of the Insured’s original request. Notification by SHL may be oral unless specifically requested in writing by the Insured.
Failure to Obtain Prior Authorization. The specific reason or reasons for upholding the Adverse Benefit Determination; Reference to the specific Plan provisions on which the determination is based; A description of any additional material or information necessary for the Claim for Benefits to be approved, modified or reversed, and an explanation of why such material or information is necessary; A description of the review procedures and the time limits applicable to such procedures;