Common use of Responding to Direct Requests By a Member for a Service Clause in Contracts

Responding to Direct Requests By a Member for a Service. When a member requests a health or long-term care service or item, IDT staff shall do all of the following: Acknowledge receipt of the request and explain to the member the process to be followed in processing the request; Using the MCO’s DHS-approved guidelines, promptly determine what the core issue is in relation to the request. Assess if the request meets a need defined in the member’s long term outcomes; Determine whether the request is for an item or service included in the Family Care Benefit package (if not, the IHCP may authorize the service only if it complies with the requirements set forth in Article VI.B.); Consult as needed with other health care professionals who have appropriate clinical expertise in treating the member's condition or disease necessary to reach a service authorization decision; Issue a prompt decision as follows:

Responding to Direct Requests By a Member for a Service. When a member requests a health or long-term care service or item, IDT staff shall do all of the following: Acknowledge receipt of the request and explain to the member the process to be followed in processing the request; Using the MCO’s DHS-approved guidelines, promptly determine what the core issue is in relation to the request. Assess if the request meets a need defined in the member’s long long-term outcomes; Determine whether the request is for an item or service included in the Family Care Benefit package (if not, the IHCP may authorize the service only if it complies with the requirements set forth in Article VI.B.); Consult as needed with other health care professionals who have appropriate clinical expertise in treating the member's condition or disease necessary to reach a service authorization decision; Issue a prompt decision as follows: