Common use of Policies and Procedures for Service Authorization Requests Clause in Contracts

Policies and Procedures for Service Authorization Requests. (A) If requiring Service Authorizations, the Contractor shall establish and follow written policies and procedures for processing requests for initial and continuing authorization of Covered Services. (B) The Contractor shall implement mechanisms to ensure consistent application of review criteria for Service Authorization decisions and consult with the requesting Provider when appropriate. (C) The Contractor shall require that any decision 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 an individual who has appropriate expertise in addressing the Enrollee’s medical, behavioral, or long-term services and supports needs. (D) The Contractor shall notify the requesting Provider, and give the Enrollee written notice of any decision to deny a Service Authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the Provider need not be in writing. (E) The Contractor shall not structure compensation to individuals or entities that conduct utilization management activities so as to provide incentives for the individual or entity to deny, limit, or discontinue, Medically Necessary Covered Services to any Enrollee. (F) The Contractor shall authorize any LTSS services, to the extent that the services are Covered Services under this Contract, based on the Enrollee’s current needs assessment and consistent with the person-centered service plan.

Policies and Procedures for Service Authorization Requests. (A) If requiring Service Authorizationsservice authorizations, the Contractor shall establish and follow written policies and procedures for processing requests for initial and continuing authorization of Covered Services. (B) The Contractor shall implement mechanisms to ensure consistent application of review criteria for Service Authorization service authorization decisions and consult with the requesting Provider when appropriate. (C) The Contractor shall require that any decision 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 an individual who has appropriate expertise in addressing the Enrollee’s medical, behavioralbehavioral health, or long-term services and supports needs. (D) The Contractor shall notify the requesting Provider, and give the Enrollee written notice of any decision to deny a Service Authorization requestRequest, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the Provider need not be in writing. (E) The Contractor shall not structure compensation to individuals or entities that conduct utilization management activities so as to provide incentives for the individual or entity to deny, limit, or discontinue, Medically Necessary Covered Services to any Enrollee. (F) The Contractor shall authorize any LTSS services, to the extent that the services are Covered Services under this Contract, based on the Enrollee’s current needs assessment and consistent with the person-centered service plan.

Policies and Procedures for Service Authorization Requests. (A) If requiring Service Authorizations, the Contractor shall establish and follow written policies and procedures for processing requests for initial and continuing authorization of Covered Services. (B) The Contractor shall implement mechanisms to ensure consistent application of review criteria for Service Authorization decisions and consult with the requesting Provider when appropriate. (C) The Contractor shall require that any decision 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 an individual who has appropriate expertise in addressing the Enrollee’s medical, behavioral, or long-term services and supports needs. (D) The Contractor shall notify the requesting Provider, and give the Enrollee written notice of any decision to deny a Service Authorization requestRequest, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the Provider need not be in writing. (E) The Contractor shall not structure compensation to individuals or entities that conduct utilization management activities so as to provide incentives for the individual or entity to deny, limit, or discontinue, Medically Necessary Covered Services to any Enrollee. (F) The Contractor shall authorize any LTSS services, to the extent that the services are Covered Services under this Contract, based on the Enrollee’s current needs assessment and consistent with the person-centered service plan.

Policies and Procedures for Service Authorization Requests. (A) If requiring Service Authorizations, the Contractor shall establish and follow written policies and procedures for processing requests for initial and continuing authorization of Covered Services. (B) The Contractor shall implement mechanisms to ensure consistent application of review criteria for Service Authorization decisions and shall consult with the requesting Provider when appropriate. (C) The Contractor shall require that any decision 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 an individual who has appropriate expertise in addressing the Enrollee’s medical, behavioral, or long-term services and supports needs. (D) The Contractor shall notify the requesting Provider, and give the Enrollee written notice of any decision to deny a Service Authorization requestRequest, or to authorize a service in an amount, duration, or scope that is less than requested. The notice to the Provider need not be in writing. (E) The Contractor shall not structure compensation to individuals or entities that conduct utilization management activities so as to provide incentives for the individual or entity to deny, limit, or discontinue, Medically Necessary Covered Services to any Enrollee. (F) The Contractor shall authorize any LTSS services, to the extent that the services are Covered Services under this Contract, based on the Enrollee’s current needs assessment and consistent with the person-centered service plan.