Common use of Service Authorization Clause in Contracts

Service Authorization. A. The Contractor may not require prior authorization for Physician, Chiropractor, CRNP, and Respiratory Care services but may require that these services require a referral from the Participant's PCP. The Contractor shall prior authorize all other Capitation Services, in accordance with the practice guidelines for authorization decisions developed as specified in Section 2.1.Y and the procedures in this Section. B. The Contractor must develop written policies and procedures for timely resolution of requests submitted on behalf of a Participant to initiate, terminate, reduce, or continue a service, including the role of the PCP and Team, consistent application of the practice guidelines for authorization decisions developed as specified in Section 2.1.Y, and consultation with the requesting Provider when appropriate. C. Any decision to deny a request for a service or to authorize a service in an amount, duration, or scope that is less than requested must be made by a health care professional who has the appropriate clinical expertise in treating the Participant's condition or disease and who was not involved and does not supervise a person involved in the development of the Participant's ISP, including the Crisis Intervention Plan and Behavioral Support Plan if applicable. D. The Contractor may not structure compensation to individuals who review requests for services in a manner that provides incentives for the individual to deny, limit, or discontinue Medically Necessary services to a Participant. E. Each Authorized Service must be the least-restrictive, most- inclusive, and cost-effective feasible option that meets the Participant's needs. F. Services may be denied or authorized in an amount, duration, or scope less than requested only on the basis of lack of medical necessity or inconsistency with accepted medical and behavioral health practices and professional standards. G. The amount, duration, or scope of a service may not be arbitrarily denied, reduced, or terminated solely because of the diagnosis, illness, or condition of a Participant. H. Any request to authorize care in a Nursing Facility or ICF setting must be submitted to BAS for review prior to authorization on the form provided by BAS, and include the ISP. The review by BAS will be within the time frames for authorization specified in this Section. If the Contractor determines that a Participant needs Residential Habilitation Services, the Contractor prior to authorizing the services must submit the ACAP Residential Habilitation Services Request Form to BAS along with any information or documentation needed to support the request to authorize Residential Habilitation Services. The Contractor must also provide BAS with any documents BAS requests as part of its review of the need for Residential Habilitation Services. BAS will review the request to authorize Residential Habilitation Services within the time frames for authorization specified in this Section. I. Within five (5) days of the Team meeting to develop ISP the Supports Coordinator must submit the ISP and supporting documentation to the Behavioral Health Practitioner for authorization of the services specified in the ISP. If the Team was unable to reach a consensus on which services to include in an ISP or the amount, duration, or scope of a service include in an ISP, the Supports Coordinator must identify the services on which the Team did and did not reach consensus and explain the positions taken by the Team members for the services on which the Team did not reach consensus. J. After the Behavioral Health Practitioner receives the ISP from the Team, he or she must, in consultation with the Medical and Clinical Directors as appropriate, resolve any areas in the ISP on which the Team did not reach consensus and decide whether to authorize services for the Participant. The Behavioral Health Practitioner may: 1. Authorize services as specified on the ISP, 2. Deny one or more services or authorize a different amount, duration, or scope of one or more services in the ISP, or 3. Request additional information from the Team to support the services included in the ISP or the amount, duration, or scope of a service included in the ISP. K. The decision on the ISP must be communicated to the Supports Coordinator and PCP in writing at the same time the Participant or the Participant's representative, as appropriate, is notified of the decision on the ISP. The notice must explain the rationale for the decision and identify any changes between the authorized ISP and the ISP submitted by the Team. L. The Contractor must notify the Participant or the Participant's representative as appropriate, in writing using a document approved by the Department, in addition to the notification to the Supports Coordinator and PCP, 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 must include the decision; the specific reasons for the decision including the right of the Participant to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested, including medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits; instructions on how a Participant can file a Complaint or Grievance if he or she does not agree with the decision and, after exhausting the Complaint or Grievance process, request a Fair Hearing; information on the Participant's right to request expedited review if the Participant's treating practitioner believes that the Participant's life, health, or ability to regain maximum function would be seriously jeopardized absent provision of the service in dispute; the Participant's right to have benefits continue pending resolution of the Complaint or Grievance; and how to request that benefits be continued; and the Participant’s right to be free from discrimination on the basis of race, color, national origin, sex, age, or disability. The notice must be written in language that is readily understandable by a layperson, at a fourth-grade reading level whenever possible and include the taglines listed in Attachment V. M. The Contractor is permitted to place appropriate limits on a service for the purpose of utilization control, provided that: 1. The services supporting Participants with ongoing or chronic conditions who require long-term services and supports are authorized in such a manner that reflects the Participant’s ongoing need for such services and supports. 2. Family planning services are provided in a manner that protects and enables the Participant’s freedom to choose the method of family planning used. N. Time Frames for Service Authorization:

Service Authorization. A. The Contractor may not require prior authorization for Physician, Chiropractor, CRNP, and Respiratory Care services but may require that these services require a referral from the Participant's PCP. The Contractor shall prior authorize all other Capitation Services, in accordance with the practice guidelines for authorization decisions developed as specified in Section 2.1.Y and the procedures in this Section. B. The Contractor must develop written policies and procedures for timely resolution of requests submitted on behalf of a Participant to initiate, terminate, reduce, or continue a service, including the role of the PCP and Team, consistent application of the practice guidelines for authorization decisions developed as specified in Section 2.1.Y, and consultation with the requesting Provider when appropriate. C. Any decision to deny a request for a service or to authorize a service in an amount, duration, or scope that is less than requested must be made by a health care professional who has the appropriate clinical expertise in treating the Participant's condition or disease and who was not involved and does not supervise a person involved in the development of the Participant's ISP, including the Crisis Intervention Plan and Behavioral Support Plan if applicable. D. The Contractor may not structure compensation to individuals who review requests for services in a manner that provides incentives for the individual to deny, limit, or discontinue Medically Necessary services to a Participant. E. Each Authorized Service must be the least-restrictive, most- most• inclusive, and cost-effective feasible option that meets the Participant's needs. F. Services may be denied or authorized in an amount, duration, or scope less than requested only on the basis of lack of medical necessity or inconsistency with accepted medical and behavioral health practices and professional standards. G. The amount, duration, or scope of a service may not be arbitrarily denied, reduced, or terminated solely because of the diagnosis, illness, or condition of a Participant. H. Any request to authorize care in a Nursing Facility or ICF setting must be submitted to BAS BSASP for review prior to authorization on the form provided by BASBSASP, and include the ISP. The review by BAS BSASP will be within the time frames for authorization specified in this Section. If the Contractor determines that a Participant needs Residential Habilitation Services, the Contractor prior to authorizing the services must submit the ACAP Residential Habilitation Services Request Form to BAS BSASP along with any information or documentation needed to support the request to authorize Residential Habilitation Services. The Contractor must also provide BAS BSASP with any documents BAS BSASP requests as part of its review of the need for Residential Habilitation Services. BAS BSASP will review the request to authorize Residential Habilitation Services within the time frames for authorization specified in this Section. I. Within five (5) days of the Team meeting to develop ISP the Supports Coordinator must submit the ISP and supporting documentation to the Behavioral Health Practitioner for authorization of the services specified in the ISP. If the Team was unable to reach a consensus on which services to include in an ISP or the amount, duration, or scope of a service include in an ISP, the Supports Coordinator must identify the services on which the Team did and did not reach consensus and explain the positions taken by the Team members for the services on which the Team did not reach consensus. J. ▇. After the Behavioral Health Practitioner receives the ISP from the Team, he or she must, in consultation with the Medical and Clinical Directors as appropriate, resolve any areas in the ISP on which the Team did not reach consensus and decide whether to authorize services for the Participant. The Behavioral Health Practitioner may: 1. Authorize services as specified on the ISP, 2. Deny one or more services or authorize a different amount, duration, or scope of one or more services in the ISP, or 3. Request additional information from the Team to support the services included in the ISP or the amount, duration, or scope of a service included in the ISP. K. The decision on the ISP must be communicated to the Supports Coordinator and PCP in writing at the same time the Participant or the Participant's representative, as appropriate, is notified of the decision on the ISP. The notice must explain the rationale for the decision and identify any changes between the authorized ISP and the ISP submitted by the Team. L. The Contractor must notify the Participant or the Participant's representative as appropriate, in writing using a document approved by the Department, in addition to the notification to the Supports Coordinator and PCP, 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 must include the decision; the specific reasons for the decision including the right of the Participant to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested, including medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits; instructions on how a Participant can file a Complaint or Grievance if he or she does not agree with the decision and, after exhausting the Complaint or Grievance process, request a Fair Hearing; information on the Participant's right to request expedited review if the Participant's treating practitioner believes that the Participant's life, health, or ability to regain maximum function would be seriously jeopardized absent provision of the service in dispute; the Participant's right to have benefits continue pending resolution of the Complaint or Grievance; and how to request that benefits be continued; and the Participant’s right to be free from discrimination on the basis of race, color, national origin, sex, age, or disability. The notice must be written in language that is readily understandable by a layperson, at a fourth-grade reading level whenever possible and include the taglines listed in Attachment V. M. The Contractor is permitted to place appropriate limits on a service for the purpose of utilization control, provided that: 1. The services supporting Participants with ongoing or chronic conditions who require long-term services and supports are authorized in such a manner that reflects the Participant’s ongoing need for such services and supports. 2. Family planning services are provided in a manner that protects and enables the Participant’s freedom to choose the method of family planning used. N. Time Frames for Service Authorization:

Service Authorization. A. The Contractor may not require prior authorization for Physician, Chiropractor, CRNP, and Respiratory Care services but may require that these services require a referral from the Participant's PCP. The Contractor shall prior authorize all other Capitation Services, in accordance with the practice guidelines for authorization decisions developed as specified in Section 2.1.Y 2.1.Z and the procedures in this Section. B. The Contractor must develop written policies and procedures for timely resolution of requests submitted on behalf of a Participant to initiate, terminate, reduce, or continue a service, including the role of the PCP and Team, consistent application of the practice guidelines for authorization decisions developed as specified in Section 2.1.Y2.1.Z, and consultation with the requesting Provider when appropriate. C. Any decision to deny a request for a service or to authorize a service in an amount, duration, or scope that is less than requested must be made by a health care professional who has the appropriate clinical expertise in treating the Participant's condition or disease and who was not involved and does not supervise a person involved in the development of the Participant's ISP, including the Crisis Intervention Plan and Behavioral Support Plan if applicable.Crisis D. The Contractor may not structure compensation to individuals who review requests for services in a manner that provides incentives for the individual to deny, limit, or discontinue Medically Necessary services to a Participant. E. Each Authorized Service must be the least-restrictive, most- inclusivemost•inclusive, and cost-effective feasible option that meets the Participant's needs. F. Services may be denied or authorized in an amount, duration, or scope less than requested only on the basis of lack of medical necessity or inconsistency with accepted medical and behavioral health practices and professional standards. G. The amount, duration, or scope of a service may not be arbitrarily denied, reduced, or terminated solely because of the diagnosis, illness, or condition of a Participant. H. Any request to authorize care in a Nursing Facility nursing facility or ICF setting must be submitted to BAS BSASP for review prior to authorization on the form provided by BAS, BSASP and include the ISP. The review by BAS BSASP will be within the time frames for authorization specified in this Section. . I. If the Contractor determines that a Participant needs Residential Habilitation Services, the Contractor prior to authorizing the services must submit the ACAP Residential Habilitation Services Request Form to BAS BSASP along with any information or documentation needed to support the request to authorize Residential Habilitation Services. The Contractor must also provide BAS BSASP with any documents BAS BSASP requests as part of its review of the need for Residential Habilitation Services. BAS BSASP will review the request to authorize Residential Habilitation Services within the time frames for authorization specified in this Section. I. Within five (5) days of the Team meeting to develop ISP the J. The Supports Coordinator must submit the ISP and in HCSis, along with supporting documentation documentation, to the Behavioral Health Practitioner for authorization of the services as specified in the ISP. If the Team was unable to reach a consensus on which services to include in an the ISP or the amount, duration, or scope of a service to include in an the ISP, the Supports Coordinator must identify the which services on which the Team did and did not reach consensus and explain the positions taken by the Team members for the services on which the Team did not reach consensusconsensus on and explain the position of each Team member. J. After K. Following submission of the ISP in HCSis, the Behavioral Health Practitioner receives the ISP from the Team, he or she must, in consultation with the Medical and Clinical Directors Directors, as appropriate, resolve any areas in the ISP on which the Team did not reach consensus and decide whether to authorize services for the Participant. Participant in accordance with the timelines outlined in Section 2.4.O. The Behavioral Health Practitioner may: 1. Authorize services as specified on the ISP, 2. Deny one or more services or authorize a different amount, duration, or scope of one or more services in the ISP, or 3. Request additional information from the Team to support the services included in the ISP or the amount, duration, or scope of a service included in the ISP. K. L. The Contractor must enter the decision on to approve and authorize services into HCSis and communicate the ISP must be communicated to the Supports Coordinator and PCP decision in writing at the same time to the Participant or the Participant's representative, as appropriate, and the prescribing Provider, if the prescribing Provider is notified not a member of the Team. The Contractor must include a copy of the updated ISP along with the written notice of the decision on to the ISP. The notice must explain Participant or the rationale for the decision and identify any changes between the authorized ISP and the ISP submitted by the TeamParticipant’s representative, as appropriate. L. The M. If services are not approved as requested, the Contractor must notify the Participant or the Participant's representative representative, as appropriate, in writing using a document approved by the Department, in addition to the notification to the Supports Coordinator and PCP, 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 must include the decision; the specific reasons for the decision including the right of the Participant to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested, including medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits; instructions on how a Participant can file a Complaint or Grievance if he or she does not agree with the decision and, after exhausting the Complaint or Grievance process, request a Fair Hearing; information on the Participant's right to request expedited review if the Participant's treating practitioner believes that the Participant's life, health, or ability to regain maximum function would be seriously jeopardized absent provision of the service in dispute; the Participant's right to have benefits continue pending resolution of the Complaint or Grievance; and how to request that benefits be continued; and the Participant’s right to be free from discrimination on Supports Coordinator, and the basis prescribing Provider, if the prescribing Provider is not a member of racethe Team, color, national origin, sex, age, or disability. The notice must be written of the decision using the appropriate template supplied by the Department in language that is readily understandable by a layperson, at a fourth-grade reading level whenever possible and include the taglines listed in Attachment V.Appendix N. M. N. The Contractor is permitted to place appropriate limits on a service for the purpose of utilization control, provided that: 1. The services supporting Participants with ongoing or chronic conditions who require long-term services and supports are authorized in such a manner that reflects the Participant’s ongoing need for such services and supports. 2. Family planning services are provided in a manner that protects and enables the Participant’s freedom to choose the method of family planning used. N. Time Frames 1. Standard Service Authorizations a. The Contractor must notify the Participant or the Participant's representative, as appropriate, of the decision to approve or deny a request for Service Authorization:services or to authorize a service in an amount, duration, or scope less than requested as expeditiously as the Participant's condition requires, at least orally, no later than five (5) days after receiving the request for service unless additional information is needed. b. If no additional information is needed, the Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. c. If additional information is needed to make a decision, the Contractor must request such information within three (3) days of receiving the request and allow seven (7) days for submission of the additional information. If the Contractor requests additional information, the Contractor must notify the Participant or the Participant's representative, as appropriate, on the date the additional information is requested, using the template found in Appendix F. i. If the requested information is provided within seven (7) days, the Contractor must make the decision to approve or deny the service and notify the Participant or the Participant's representative, as appropriate, of the decision orally within two (2) business days of receipt of the additional information. The Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. ii. If the requested information is not received within seven (7) days, the Contractor must make the decision to approve or deny the service based upon the available information and notify the Participant or the Participant's representative, as appropriate, of the decision orally within two (2) business days after the additional information was to have been received. The Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made.

Service Authorization. A. The Contractor may not require prior authorization for Physician, Chiropractor, CRNP, and Respiratory Care services but may require that these services require a referral from the Participant's PCP. The Contractor shall prior authorize all other Capitation Services, in accordance with the practice guidelines for authorization decisions developed as specified in Section 2.1.Y and the procedures in this Section. B. The Contractor must develop written policies and procedures for timely resolution of requests submitted on behalf of a Participant to initiate, terminate, reduce, or continue a service, including the role of the PCP and Team, consistent application of the practice guidelines for authorization decisions developed as specified in Section 2.1.Y, and consultation with the requesting Provider when appropriate. C. Any decision to deny a request for a service or to authorize a service in an amount, duration, or scope cope that is less than requested must be made by a health care professional who has the appropriate clinical expertise in treating the Participant's condition or disease and who was not involved and does not supervise a person involved in the development of the Participant's Initial ISP and FBA-Based ISP, including the Crisis Intervention Plan and Behavioral Support Plan if applicablePlan. D. The Contractor may not structure compensation to individuals who review requests for services in a manner that provides incentives for the individual to deny, limit, or discontinue Medically Necessary services to a Participant. E. Each Authorized Service must be the least-restrictive, most- inclusive, and cost-effective feasible option that meets the Participant's needs. F. Services may be denied or authorized in an amount, duration, or scope less than requested only on the basis of lack of medical necessity or inconsistency with accepted medical and behavioral health practices and professional standards. G. The amount, duration, or scope of a service may not be arbitrarily denied, reduced, or terminated solely because of the diagnosis, illness, or condition of a Participant. H. Any request to authorize care in a Nursing Facility or ICF setting must be submitted to BAS for review prior to authorization on the form provided by BAS, and include the FBA-Based ISP. The review by BAS will be within the time frames timeframes for authorization specified in this Section. If the Contractor determines that a Participant needs Residential Habilitation Servicesservices, the Contractor prior to authorizing the services must submit the ACAP Residential Habilitation Services Request Form to BAS along with any information or documentation needed to support the request to authorize Residential Habilitation Servicesservices. The Contractor must also provide BAS with any documents BAS requests as part of its review of the need for Residential Habilitation Servicesservices. BAS will review the request to authorize Residential Habilitation Services services within the time frames timeframes for authorization specified in this Section. I. Within five (5) days of the Team meeting to develop the Initial ISP or the FBA-Based ISP the Supports Coordinator must submit the Initial ISP or the FBA-Based ISP and supporting documentation to the Behavioral Health Practitioner for authorization of the services specified in the Initial ISP or FBA-Based ISP. If the Team was unable to reach a consensus on which services to include in an ISP or the amount, duration, or scope of a service include in an ISP, the Supports Coordinator must identify the services on which the Team did and did not reach consensus and explain the positions taken by the Team members for the services on which the Team did not reach consensus. J. After the Behavioral Health Practitioner receives the Initial ISP or the FBA Based ISP from the Team, he or she must, in consultation with the Medical and Clinical Directors Director as appropriate, resolve any areas in the ISP on which the Team did not reach consensus and decide whether to authorize services for the Participant. The Behavioral Health Practitioner may: 1. Authorize services as specified on the ISP, 2. Deny one or more services or authorize a different amount, duration, or scope of one or more services in the ISP, or 3. Request additional information from the Team to support the services included in the ISP or the amount, duration, or scope of a service included in the ISP. K. The decision on the Initial ISP and the FBA-Based ISP must be communicated to the Supports Coordinator and PCP in writing at the same time the Participant or the Participant's representative, as appropriate, is notified of the decision on the ISP. The notice must explain the rationale for the decision and identify any changes between the authorized ISP and the ISP submitted by the Team. L. The Contractor must notify the Participant or the Participant's representative as appropriate, in writing using a document approved by the Department, in addition to the notification to the Supports Coordinator and PCP, 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 must include the decision; the specific reasons for the decision including the right of the Participant to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested, including medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limitsdecision; instructions on how a Participant can file a Complaint or Grievance if he or she does not agree with the decision and, after exhausting the Complaint or Grievance process, request a DHS Fair Hearing; information on the Participant's right to request expedited review if the Participant's treating practitioner believes that the Participant's life, health, or ability to regain maximum function would be seriously jeopardized absent provision of the service in dispute; and the Participant's right to have benefits continue pending resolution of the Complaint Grievance or GrievanceDHS Fair Hearing; and how to request that benefits be continued; and the Participant’s right to be free from discrimination on the basis of race, color, national origin, sex, age, or disability. The notice must be written in language that is readily understandable by a layperson, at a fourth-grade reading level whenever possible and include the taglines listed in Attachment V.possible. M. The Contractor is permitted to place appropriate limits on a service for the purpose of utilization control, provided that: 1. The services supporting Participants with ongoing or chronic conditions who require long-term services and supports are authorized in such a manner that reflects the Participant’s ongoing need for such services and supports. 2. Family planning services are provided in a manner that protects and enables the Participant’s freedom to choose the method of family planning used. N. Time Frames for Service Authorization: 1. Standard Service Authorizations a. The Contractor must notify the Participant or the Participant's representative, as appropriate, of the decision to approve or deny a request for services or to authorize a service in an amount, duration, or scope less than requested as expeditiously as the Participant's condition requires, at least orally, no later than five (5) days after receiving the request for service unless additional information is needed. If no additional information is needed, the Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Support Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. b. If additional information is needed to make a decision, the Contractor must request such information within three (3) days of receiving the request and allow seven

Service Authorization. A. The Contractor may not require prior authorization for Physician, Chiropractor, CRNP, and Respiratory Care services but may require that these services require a referral from the Participant's PCP. The Contractor shall prior authorize all other Capitation Services, in accordance with the practice guidelines for authorization decisions developed as specified in Section 2.1.Y 2.1.Z and the procedures in this Section. B. The Contractor must develop written policies and procedures for timely resolution of requests submitted on behalf of a Participant to initiate, terminate, reduce, or continue a service, including the role of the PCP and Team, consistent application of the practice guidelines for authorization decisions developed as specified in Section 2.1.Y2.1.Z, and consultation with the requesting Provider when appropriate. C. Any decision to deny a request for a service or to authorize a service in an amount, duration, or scope that is less than requested must be made by a health care professional who has the appropriate clinical expertise in treating the Participant's condition or disease and who was not involved and does not supervise a person involved in the development of the Participant's ISP, including the Crisis Intervention Plan and Behavioral Support Plan if applicable. D. The Contractor may not structure compensation to individuals who review requests for services in a manner that provides incentives for the individual to deny, limit, or discontinue Medically Necessary services to a Participant. E. Each Authorized Service must be the least-restrictive, most- most-inclusive, and cost-effective feasible option that meets the Participant's needs. F. Services may be denied or authorized in an amount, duration, or scope less than requested only on the basis of lack of medical necessity or inconsistency with accepted medical and behavioral health practices and professional standards. G. The amount, duration, or scope of a service may not be arbitrarily denied, reduced, or terminated solely because of the diagnosis, illness, or condition of a Participant. H. Any request to authorize care in a Nursing Facility nursing facility or ICF setting must be submitted to BAS BSASP for review prior to authorization on the form provided by BAS, BSASP and include the ISP. The review by BAS BSASP will be within the time frames for authorization specified in this Section. . I. If the Contractor determines that a Participant needs Residential Habilitation Services, the Contractor prior to authorizing the services must submit the ACAP Residential Habilitation Services Request Form to BAS BSASP along with any information or documentation needed to support the request to authorize Residential Habilitation Services. The Contractor must also provide BAS BSASP with any documents BAS BSASP requests as part of its review of the need for Residential Habilitation Services. BAS BSASP will review the request to authorize Residential Habilitation Services within the time frames for authorization specified in this Section. I. Within five (5) days of the Team meeting to develop ISP the J. The Supports Coordinator must submit the ISP and in HCSis, along with supporting documentation documentation, to the Behavioral Health Practitioner for authorization of the services as specified in the ISP. If the Team was unable to reach a consensus on which services to include in an the ISP or the amount, duration, or scope of a service to include in an the ISP, the Supports Coordinator must identify the which services on which the Team did and did not reach consensus and explain the positions taken by the Team members for the services on which the Team did not reach consensusconsensus on and explain the position of each Team member. J. After K. Following submission of the ISP in HCSis, the Behavioral Health Practitioner receives the ISP from the Team, he or she must, in consultation with the Medical and Clinical Directors Directors, as appropriate, resolve any areas in the ISP on which the Team did not reach consensus and decide whether to authorize services for the Participant. Participant in accordance with the timelines outlined in Section 2.4.O. The Behavioral Health Practitioner may: 1. Authorize services as specified on the ISP, 2. Deny one or more services or authorize a different amount, duration, or scope of one or more services in the ISP, or 3. Request additional information from the Team to support the services included in the ISP or the amount, duration, or scope of a service included in the ISP. K. L. The Contractor must enter the decision on to approve and authorize services into HCSis and communicate the ISP must be communicated to the Supports Coordinator and PCP decision in writing at the same time to the Participant or the Participant's representative, as appropriate, and the prescribing Provider, if the prescribing Provider is notified not a member of the Team. The Contractor must include a copy of the updated ISP along with the written notice of the decision on to the ISP. The notice must explain Participant or the rationale for the decision and identify any changes between the authorized ISP and the ISP submitted by the TeamParticipant’s representative, as appropriate. L. The M. If services are not approved as requested, the Contractor must notify the Participant or the Participant's representative representative, as appropriate, in writing using a document approved by the Department, in addition to the notification to the Supports Coordinator and PCP, 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 must include the decision; the specific reasons for the decision including the right of the Participant to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested, including medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits; instructions on how a Participant can file a Complaint or Grievance if he or she does not agree with the decision and, after exhausting the Complaint or Grievance process, request a Fair Hearing; information on the Participant's right to request expedited review if the Participant's treating practitioner believes that the Participant's life, health, or ability to regain maximum function would be seriously jeopardized absent provision of the service in dispute; the Participant's right to have benefits continue pending resolution of the Complaint or Grievance; and how to request that benefits be continued; and the Participant’s right to be free from discrimination on Supports Coordinator, and the basis prescribing Provider, if the prescribing Provider is not a member of racethe Team, color, national origin, sex, age, or disability. The notice must be written of the decision using the appropriate template supplied by the Department in language that is readily understandable by a layperson, at a fourth-grade reading level whenever possible and include the taglines listed in Attachment V.Appendix N. M. N. The Contractor is permitted to place appropriate limits on a service for the purpose of utilization control, provided that: 1. The that the services supporting Participants with ongoing or chronic conditions who require long-term services and supports are authorized in such a manner that reflects the Participant’s ongoing need for such services and supports. 2. Family planning services are provided in a manner that protects and enables the Participant’s freedom to choose the method of family planning used. N. O. Time Frames for Service Authorization: 1. Standard Service Authorizations a. The Contractor must notify the Participant or the Participant's representative, as appropriate, of the decision to approve or deny a request for services or to authorize a service in an amount, duration, or scope less than requested as expeditiously as the Participant's condition requires, at least orally, no later than five (5) days after receiving the request for service unless additional information is needed. b. If no additional information is needed, the Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. c. If additional information is needed to make a decision, the Contractor must request such information within three (3) days of receiving the request and allow seven (7) days for submission of the additional information. If the Contractor requests additional information, the Contractor must notify the Participant or the Participant's representative, as appropriate, on the date the additional information is requested, using the template found in Appendix F. i. If the requested information is provided within seven (7) days, the Contractor must make the decision to approve or deny the service and notify the Participant or the Participant's representative, as appropriate, of the decision orally within two (2) business days of receipt of the additional information. The Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. ii. If the requested information is not received within seven (7) days, the Contractor must make the decision to approve or deny the service based upon the available information and notify the Participant or the Participant's representative, as appropriate, of the decision orally within two (2) business days after the additional information was to have been received. The Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made.

Service Authorization. A. The Contractor may not require prior authorization for Physician, Chiropractor, CRNP, and Respiratory Care services but may require that these services require a referral from the Participant's PCP. The Contractor shall prior authorize all other Capitation Services, in accordance with the practice guidelines for authorization decisions developed as specified in Section 2.1.Y 2.1.Z and the procedures in this Section. B. The Contractor must develop written policies and procedures for timely resolution of requests submitted on behalf of a Participant to initiate, terminate, reduce, or continue a service, including the role of the PCP and Team, consistent application of the practice guidelines for authorization decisions developed as specified in Section 2.1.Y2.1.Z, and consultation with the requesting Provider when appropriate. C. Any decision to deny a request for a service or to authorize a service in an amount, duration, or scope that is less than requested must be made by a health care professional who has the appropriate clinical expertise in treating the Participant's condition or disease and who was not involved and does not supervise a person involved in the development of the Participant's ISP, including the Crisis Intervention Plan and Behavioral Support Plan if applicable. D. The Contractor may not structure compensation to individuals who review requests for services in a manner that provides incentives for the individual to deny, limit, or discontinue Medically Necessary services to a Participant. E. Each Authorized Service must be the least-restrictive, most- most-inclusive, and cost-effective feasible option that meets the Participant's needs. F. Services may be denied or authorized in an amount, duration, or scope less than requested only on the basis of lack of medical necessity or inconsistency with accepted medical and behavioral health practices and professional standards. G. The amount, duration, or scope of a service may not be arbitrarily denied, reduced, or terminated solely because of the diagnosis, illness, or condition of a Participant. H. Any request to authorize care in a Nursing Facility nursing facility or ICF setting must be submitted to BAS ODP for review prior to authorization on the form provided by BAS, ODP and include the ISP. The review by BAS ODP will be within the time frames for authorization specified in this Section. . I. If the Contractor determines that a Participant needs Residential Habilitation Services, the Contractor prior to authorizing the services must submit the ACAP Residential Habilitation Services Request Form to BAS ODP along with any information or documentation needed to support the request to authorize Residential Habilitation Services. The Contractor must also provide BAS ODP with any documents BAS ODP requests as part of its review of the need for Residential Habilitation Services. BAS ODP will review the request to authorize Residential Habilitation Services within the time frames for authorization specified in this Section. I. Within five (5) days of the Team meeting to develop ISP the J. The Supports Coordinator must submit the ISP and in HCSis, along with supporting documentation documentation, to the Behavioral Health Practitioner for authorization of the services as specified in the ISP. If the Team was unable to reach a consensus on which services to include in an the ISP or the amount, duration, or scope of a service to include in an the ISP, the Supports Coordinator must identify the which services on which the Team did and did not reach consensus and explain the positions taken by the Team members for the services on which the Team did not reach consensusconsensus on and explain the position of each Team member. J. After K. Following submission of the ISP in HCSis, the Behavioral Health Practitioner receives the ISP from the Team, he or she must, in consultation with the Medical and Clinical Directors Directors, as appropriate, resolve any areas in the ISP on which the Team did not reach consensus and decide whether to authorize services for the Participant. Participant in accordance with the timelines outlined in Section 2.4.O. The Behavioral Health Practitioner may: 1. Authorize services as specified on the ISP, 2. Deny one or more services or authorize a different amount, duration, or scope of one or more services in the ISP, or 3. Request additional information from the Team to support the services included in the ISP or the amount, duration, or scope of a service included in the ISP. K. L. The Contractor must enter the decision on to approve and authorize services into HCSis and communicate the ISP must be communicated to the Supports Coordinator and PCP decision in writing at the same time to the Participant or the Participant's representative, as appropriate, and the prescribing Provider, if the prescribing Provider is notified not a member of the Team. The Contractor must include a copy of the updated ISP along with the written notice of the decision on to the ISP. The notice must explain Participant or the rationale for the decision and identify any changes between the authorized ISP and the ISP submitted by the TeamParticipant’s representative, as appropriate. L. The M. If services are not approved as requested, the Contractor must notify the Participant or the Participant's representative representative, as appropriate, in writing using a document approved by the Department, in addition to the notification to the Supports Coordinator and PCP, 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 must include the decision; the specific reasons for the decision including the right of the Participant to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested, including medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits; instructions on how a Participant can file a Complaint or Grievance if he or she does not agree with the decision and, after exhausting the Complaint or Grievance process, request a Fair Hearing; information on the Participant's right to request expedited review if the Participant's treating practitioner believes that the Participant's life, health, or ability to regain maximum function would be seriously jeopardized absent provision of the service in dispute; the Participant's right to have benefits continue pending resolution of the Complaint or Grievance; and how to request that benefits be continued; and the Participant’s right to be free from discrimination on Supports Coordinator, and the basis prescribing Provider, if the prescribing Provider is not a member of racethe Team, color, national origin, sex, age, or disability. The notice must be written of the decision using the appropriate template supplied by the Department in language that is readily understandable by a layperson, at a fourth-grade reading level whenever possible and include the taglines listed in Attachment V.Appendix N. M. N. The Contractor is permitted to place appropriate limits on a service for the purpose of utilization control, provided that: 1. The that the services supporting Participants with ongoing or chronic conditions who require long-term services and supports are authorized in such a manner that reflects the Participant’s ongoing need for such services and supports. 2. Family planning services are provided in a manner that protects and enables the Participant’s freedom to choose the method of family planning used. N. O. Time Frames for Service Authorization: 1. Standard Service Authorizations a. The Contractor must notify the Participant or the Participant's representative, as appropriate, of the decision to approve or deny a request for services or to authorize a service in an amount, duration, or scope less than requested as expeditiously as the Participant's condition requires, at least orally, no later than five (5) days after receiving the request for service unless additional information is needed. b. If no additional information is needed, the Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. c. If additional information is needed to make a decision, the Contractor must request such information within three (3) days of receiving the request and allow seven (7) days for submission of the additional information. If the Contractor requests additional information, the Contractor must notify the Participant or the Participant's representative, as appropriate, on the date the additional information is requested, using the template found in Appendix F. i. If the requested information is provided within seven (7) days, the Contractor must make the decision to approve or deny the service and notify the Participant or the Participant's representative, as appropriate, of the decision orally within two (2) business days of receipt of the additional information. The Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. ii. If the requested information is not received within seven (7) days, the Contractor must make the decision to approve or deny the service based upon the available information and notify the Participant or the Participant's representative, as appropriate, of the decision orally within two (2) business days after the additional information was to have been received. The Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made.

Service Authorization. A. The Contractor may not require prior authorization for Physician, Chiropractor, CRNP, and Respiratory Care services but may require that these services require a referral from the Participant's PCP. The Contractor shall prior authorize all other Capitation Services, in accordance with the practice guidelines for authorization decisions developed as specified in Section 2.1.Y 2.1.Z and the procedures in this Section. B. The Contractor must develop written policies and procedures for timely resolution of requests submitted on behalf of a Participant to initiate, terminate, reduce, or continue a service, including the role of the PCP and Team, consistent application of the practice guidelines for authorization decisions developed as specified in Section 2.1.Y2.1.Z, and consultation with the requesting Provider when appropriate. C. Any decision to deny a request for a service or to authorize a service in an amount, duration, or scope that is less than requested must be made by a health care professional who has the appropriate clinical expertise in treating the Participant's condition or disease and who was not involved and does not supervise a person involved in the development of the Participant's ISP, including the Crisis Intervention Plan and Behavioral Support Plan if applicable. D. The Contractor may not structure compensation to individuals who review requests for services in a manner that provides incentives for the individual to deny, limit, or discontinue Medically Necessary services to a Participant. E. Each Authorized Service must be the least-restrictive, most- inclusive, and cost-effective feasible option that meets the Participant's needs. F. Services may be denied or authorized in an amount, duration, or scope less than requested only on the basis of lack of medical necessity or inconsistency with accepted medical and behavioral health practices and professional standards. G. The amount, duration, or scope of a service may not be arbitrarily denied, reduced, or terminated solely because of the diagnosis, illness, or condition of a Participant. H. Any request to authorize care in a Nursing Facility or ICF setting must be submitted to BAS BSASP for review prior to authorization on the form provided by BAS, BSASP and include the ISP. The review by BAS BSASP will be within the time frames for authorization specified in this Section. . I. If the Contractor determines that a Participant needs Residential Habilitation Services, the Contractor prior to authorizing the services must submit the ACAP Residential Habilitation Services Request Form to BAS BSASP along with any information or documentation needed to support the request to authorize Residential Habilitation Services. The Contractor must also provide BAS BSASP with any documents BAS BSASP requests as part of its review of the need for Residential Habilitation Services. BAS BSASP will review the request to authorize Residential Habilitation Services within the time frames for authorization specified in this Section. I. Within five (5) days of the Team meeting to develop ISP the J. The Supports Coordinator must submit the ISP and in HCSis, along with supporting documentation documentation, to the Behavioral Health Practitioner for authorization of the services as specified in the ISP. If the Team was unable to reach a consensus on which services to include in an the ISP or the amount, duration, or scope of a service include in an the ISP, the Supports Coordinator must identify the which services on which the Team did and did not reach consensus and explain the positions taken by the Team members for the services on which the Team did not reach consensusconsensus on and explain the position of each Team member. J. After ▇. Following submission of the ISP in HCSis, the Behavioral Health Practitioner receives the ISP from the Team, he or she must, in consultation with the Medical and Clinical Directors Directors, as appropriate, resolve any areas in the ISP on which the Team did not reach consensus and decide whether to authorize services for the Participant. Participant in accordance with the timelines outlined in Section 2.4.O. The Behavioral Health Practitioner may: 1. Authorize services as specified on the ISP, 2. Deny one or more services or authorize a different amount, duration, or scope of one or more services in the ISP, or 3. Request additional information from the Team to support the services included in the ISP or the amount, duration, or scope of a service included in the ISP. K. L. The Contractor must enter the decision on to approve and authorize services into HCSis and communicate the ISP must be communicated to the Supports Coordinator and PCP decision in writing at the same time to the Participant or the Participant's representative, as appropriate, and the prescribing Provider, if the prescribing Provider is notified not a member of the Team. The Contractor must include a copy of the updated ISP along with the written notice of the decision on to the ISP. The notice must explain Participant or the rationale for the decision and identify any changes between the authorized ISP and the ISP submitted by the TeamParticipant’s representative, as appropriate. L. The M. If services are not approved as requested, the Contractor must notify the Participant or the Participant's representative representative, as appropriate, in writing using a document approved by the Department, in addition to the notification to the Supports Coordinator and PCP, 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 must include the decision; the specific reasons for the decision including the right of the Participant to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested, including medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits; instructions on how a Participant can file a Complaint or Grievance if he or she does not agree with the decision and, after exhausting the Complaint or Grievance process, request a Fair Hearing; information on the Participant's right to request expedited review if the Participant's treating practitioner believes that the Participant's life, health, or ability to regain maximum function would be seriously jeopardized absent provision of the service in dispute; the Participant's right to have benefits continue pending resolution of the Complaint or Grievance; and how to request that benefits be continued; and the Participant’s right to be free from discrimination on Supports Coordinator, and the basis prescribing Provider, if the prescribing Provider is not a member of racethe Team, color, national origin, sex, age, or disability. The notice must be written of the decision using the appropriate template supplied by the Department in language that is readily understandable by a layperson, at a fourth-grade reading level whenever possible and include the taglines listed in Attachment V.Appendix N. M. N. The Contractor is permitted to place appropriate limits on a service for the purpose of utilization control, provided that: 1. The services supporting Participants with ongoing or chronic conditions who require long-term services and supports are authorized in such a manner that reflects the Participant’s ongoing need for such services and supports. 2. Family planning services are provided in a manner that protects and enables the Participant’s freedom to choose the method of family planning used. N. Time Frames 1. Standard Service Authorizations a. The Contractor must notify the Participant or the Participant's representative, as appropriate, of the decision to approve or deny a request for Service Authorization:services or to authorize a service in an amount, duration, or scope less than requested as expeditiously as the Participant's condition requires, at least orally, no later than five (5) days after receiving the request for service unless additional information is needed. b. If no additional information is needed, the Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Support Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. c. If additional information is needed to make a decision, the Contractor must request such information within three (3) days of receiving the request and allow seven (7) days for submission of the additional information. If the Contractor requests additional information, the Contractor must notify the Participant or the Participant's representative, as appropriate, on the date the additional information is requested, using the template found in Appendix F. i. If the requested information is provided within seven (7) days, the Contractor must make the decision to approve or deny the service and notify the Participant or the Participant's representative, as appropriate, of the decision orally within two

Service Authorization. A. The Contractor may not require prior authorization for Physician, Chiropractor, CRNP, and Respiratory Care services but may require that these services require a referral from the Participant's PCP. The Contractor shall prior authorize all other Capitation Services, in accordance with the practice guidelines for authorization decisions developed as specified in Section 2.1.Y 2.1.Z and the procedures in this Section. B. The Contractor must develop written policies and procedures for timely resolution of requests submitted on behalf of a Participant to initiate, terminate, reduce, or continue a service, including the role of the PCP and Team, consistent application of the practice guidelines for authorization decisions developed as specified in Section 2.1.Y2.1.Z, and consultation with the requesting Provider when appropriate. C. Any decision to deny a request for a service or to authorize a service in an amount, duration, or scope that is less than requested must be made by a health care professional who has the appropriate clinical expertise in treating the Participant's condition or disease and who was not involved and does not supervise a person involved in the development of the Participant's ISP, including the Crisis Intervention Plan and Behavioral Support Plan if applicable.Crisis D. The Contractor may not structure compensation to individuals who review requests for services in a manner that provides incentives for the individual to deny, limit, or discontinue Medically Necessary services to a Participant. E. Each Authorized Service must be the least-restrictive, most- inclusivemost•inclusive, and cost-effective feasible option that meets the Participant's needs. F. Services may be denied or authorized in an amount, duration, or scope less than requested only on the basis of lack of medical necessity or inconsistency with accepted medical and behavioral health practices and professional standards. G. The amount, duration, or scope of a service may not be arbitrarily denied, reduced, or terminated solely because of the diagnosis, illness, or condition of a Participant. H. Any request to authorize care in a Nursing Facility nursing facility or ICF setting must be submitted to BAS BSASP for review prior to authorization on the form provided by BAS, BSASP and include the ISP. The review by BAS BSASP will be within the time frames for authorization specified in this Section. . I. If the Contractor determines that a Participant needs Residential Habilitation Services, the Contractor prior to authorizing the services must submit the ACAP Residential Habilitation Services Request Form to BAS BSASP along with any information or documentation needed to support the request to authorize Residential Habilitation Services. The Contractor must also provide BAS BSASP with any documents BAS BSASP requests as part of its review of the need for Residential Habilitation Services. BAS BSASP will review the request to authorize Residential Habilitation Services within the time frames for authorization specified in this Section. I. Within five (5) days of the Team meeting to develop ISP the J. The Supports Coordinator must submit the ISP and in HCSis, along with supporting documentation documentation, to the Behavioral Health Practitioner for authorization of the services as specified in the ISP. If the Team was unable to reach a consensus on which services to include in an the ISP or the amount, duration, or scope of a service to include in an the ISP, the Supports Coordinator must identify the which services on which the Team did and did not reach consensus and explain the positions taken by the Team members for the services on which the Team did not reach consensusconsensus on and explain the position of each Team member. J. After ▇. Following submission of the ISP in HCSis, the Behavioral Health Practitioner receives the ISP from the Team, he or she must, in consultation with the Medical and Clinical Directors Directors, as appropriate, resolve any areas in the ISP on which the Team did not reach consensus and decide whether to authorize services for the Participant. Participant in accordance with the timelines outlined in Section 2.4.O. The Behavioral Health Practitioner may: 1. Authorize services as specified on the ISP, 2. Deny one or more services or authorize a different amount, duration, or scope of one or more services in the ISP, or 3. Request additional information from the Team to support the services included in the ISP or the amount, duration, or scope of a service included in the ISP. K. L. The Contractor must enter the decision on to approve and authorize services into HCSis and communicate the ISP must be communicated to the Supports Coordinator and PCP decision in writing at the same time to the Participant or the Participant's representative, as appropriate, and the prescribing Provider, if the prescribing Provider is notified not a member of the Team. The Contractor must include a copy of the updated ISP along with the written notice of the decision on to the ISP. The notice must explain Participant or the rationale for the decision and identify any changes between the authorized ISP and the ISP submitted by the TeamParticipant’s representative, as appropriate. L. The M. If services are not approved as requested, the Contractor must notify the Participant or the Participant's representative representative, as appropriate, in writing using a document approved by the Department, in addition to the notification to the Supports Coordinator and PCP, 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 must include the decision; the specific reasons for the decision including the right of the Participant to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested, including medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits; instructions on how a Participant can file a Complaint or Grievance if he or she does not agree with the decision and, after exhausting the Complaint or Grievance process, request a Fair Hearing; information on the Participant's right to request expedited review if the Participant's treating practitioner believes that the Participant's life, health, or ability to regain maximum function would be seriously jeopardized absent provision of the service in dispute; the Participant's right to have benefits continue pending resolution of the Complaint or Grievance; and how to request that benefits be continued; and the Participant’s right to be free from discrimination on Supports Coordinator, and the basis prescribing Provider, if the prescribing Provider is not a member of racethe Team, color, national origin, sex, age, or disability. The notice must be written of the decision using the appropriate template supplied by the Department in language that is readily understandable by a layperson, at a fourth-grade reading level whenever possible and include the taglines listed in Attachment V.Appendix N. M. N. The Contractor is permitted to place appropriate limits on a service for the purpose of utilization control, provided that: 1. The services supporting Participants with ongoing or chronic conditions who require long-term services and supports are authorized in such a manner that reflects the Participant’s ongoing need for such services and supports. 2. Family planning services are provided in a manner that protects and enables the Participant’s freedom to choose the method of family planning used. N. Time Frames 1. Standard Service Authorizations a. The Contractor must notify the Participant or the Participant's representative, as appropriate, of the decision to approve or deny a request for Service Authorization:services or to authorize a service in an amount, duration, or scope less than requested as expeditiously as the Participant's condition requires, at least orally, no later than five (5) days after receiving the request for service unless additional information is needed. b. If no additional information is needed, the Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. c. If additional information is needed to make a decision, the Contractor must request such information within three (3) days of receiving the request and allow seven (7) days for submission of the additional information. If the Contractor requests additional information, the Contractor must notify the Participant or the Participant's representative, as appropriate, on the date the additional information is requested, using the template found in Appendix F. i. If the requested information is provided within seven (7) days, the Contractor must make the decision to approve or deny the service and notify the Participant or the Participant's representative, as appropriate, of the decision orally within two (2) business days of receipt of the additional information. The Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made. ii. If the requested information is not received within seven (7) days, the Contractor must make the decision to approve or deny the service based upon the available information and notify the Participant or the Participant's representative, as appropriate, of the decision orally within two (2) business days after the additional information was to have been received. The Contractor must mail or hand deliver written notice of the decision to the Participant or the Participant's representative, as appropriate; the Supports Coordinator; and the prescribing Provider, if the prescribing Provider is not a member of the Team, within two (2) business days after the decision is made.