Common use of Utilization Review Clause in Contracts

Utilization Review. The Contractor agrees to have written utilization review policies and procedures that include protocols for denial of services, prior approval, physician profiling and retrospective review of claims. As part of its utilization review function, the Contractor also agrees to have processes to identify utilization problems and undertake corrective action. As part of this function, the Contractor shall have a structured process for the approval or denial of covered services. This shall include, in the instance of denials, formal written notification to the member and the requesting or treating provider of the denial, its basis and any applicable appeal rights and procedures. The Contractor shall provide standard authorization decisions within fourteen (14) calendar days of the request for authorization unless the member requests an extension, or the Contractor justifies a need for additional information and the Contractor can demonstrate how the extension is in the member’s interest. If there is a fourteen (14) day extension, the Contractor will comply with all requirements as specified in 42 CFR 438.404(c). The Contractor is permitted to conduct utilization review and place appropriate limits on services while supporting member with ongoing or chronic conditions so long as services are authorized in a manner that reflects the member’s ongoing needs for such services and supports. The Contractor must make an expedited service authorization decision and provide notice as expeditiously as the enrollee’s health condition requires and no later than seventy-two (72) hours after receipt of the request for service for cases in which a provider indicates, or the Contractor determines that following the standard authorization timeframe could seriously jeopardize the enrollee's life or health or his/her ability to attain, maintain, or regain maximum function. The Contractor may extend the seventy-two (72) hour expedited authorization by up to fourteen (14) calendar days if the member requests an extension, or if the Contractor can justify a need for the additional time and the extension is in the member’s best interest. The Contractor shall demonstrate to EOHHS that compensation to individuals or entities that conduct utilization management activities is not structured to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any member. The Contractor shall define service authorization in a manner that at least includes an enrollee’s request for the provision of services as required by 42 C.F.R. § 431.210. Contractor must maintain written policies and procedures that cover the language and format of notices of adverse actions: • Written notice must be translated for individuals who speak prevalent non-English languages, as defined by the State per 42 C.F.R. § 438.10 (c). • Notice must include language clarifying that oral interpretation is available for all languages and how to access it. • Written material must use easily understood language and format, be available in alternative formats, and in an appropriate manner that takes into consideration of those with special needs. • Enrollees and potential enrollees must be informed that information is available in all tentative formats and how to access those formats.

Utilization Review. The Contractor agrees to have written utilization review policies and procedures that include protocols for denial of services, prior approval, physician profiling and retrospective review of claims. As part of its utilization review function, the Contractor also agrees to have processes to identify utilization problems and undertake corrective action. As part of this function, the Contractor shall have a structured process for the approval or denial of covered services. This shall include, in the instance of denials, formal written notification to the member and the requesting or treating provider of the denial, its basis and any applicable appeal rights and procedures. The Contractor shall provide standard authorization decisions within fourteen (14) calendar days of the request for authorization unless the member requests an extension, or the Contractor justifies a need for additional information and the Contractor can demonstrate how the extension is in the member’s interest. If there is a fourteen (14) day extension, the Contractor will comply with all requirements as specified in 42 CFR 438.404(c). The Contractor is permitted to conduct utilization review and place appropriate limits on services while supporting member with ongoing or chronic conditions so long as services are authorized in a manner that reflects the member’s ongoing needs for such services and supports. The Contractor must make an expedited service authorization decision and provide notice as expeditiously as the enrollee’s health condition requires and no later than seventy-two (72) hours after receipt of the request for service for cases in which a provider indicates, or the Contractor determines that following the standard authorization timeframe could seriously jeopardize the enrollee's life or health or his/her ability to attain, maintain, or regain maximum function. The Contractor may extend the seventy-two (72) hour expedited authorization by up to fourteen (14) calendar days if the member requests an extension, or if the Contractor can justify a need for the additional time and the extension is in the member’s best interest. The Contractor shall demonstrate to EOHHS that compensation to individuals or entities that conduct utilization management activities is not structured to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any member. The Contractor shall define service authorization in a manner that at least includes an enrollee’s request for the provision of services as required by 42 C.F.R. § 431.210. Contractor must maintain written policies and procedures that cover the language and format of notices of adverse actions: • Written notice must be translated for individuals who speak prevalent non-English languages, as defined by the State per 42 C.F.R. § 438.10 (c). • Notice must include language clarifying that oral interpretation is available for all languages and how to access it. • Written material must use easily understood language and format, be available in alternative formats, and in an appropriate manner that takes into consideration of those with special needs. • Enrollees and potential enrollees must be informed that information is available in all tentative formats and how to access those formats.fourteen

Utilization Review. The Contractor agrees to have written utilization review policies and procedures that include protocols for denial of services, prior approval, physician profiling and retrospective review of claims. As part of its utilization review function, the Contractor also agrees to have processes to identify utilization problems and undertake corrective action. As part of this function, the Contractor shall have a structured process for the approval or denial of covered services. This shall include, in the instance of denials, formal written notification to the member and the requesting or treating provider of the denial, its basis and any applicable appeal rights and procedures. The Contractor shall provide standard authorization decisions within fourteen (14) calendar days of the request for authorization unless the member requests an extension, or the Contractor justifies a need for additional information and the Contractor can demonstrate how the extension is in the member’s interest. If there is a fourteen (14) day extension, the Contractor will comply with all requirements as specified in 42 CFR § 438.404(c). The Contractor is permitted to conduct utilization review and place appropriate limits on services while supporting member with ongoing or chronic conditions so long as services are authorized in a manner that reflects the member’s ongoing needs for such services and supports. The Contractor must make an expedited service authorization decision and provide notice as expeditiously as the enrollee’s health condition requires and no later than seventy-two (72) hours after receipt of the request for service for cases in which a provider indicates, or the Contractor determines that following the standard authorization timeframe could seriously jeopardize the enrollee's life or health or his/her ability to attain, maintain, or regain maximum function. The Contractor may extend the seventy-two (72) hour expedited authorization by up to fourteen (14) calendar days if the member requests an extension, or if the Contractor can justify a need for the additional time and the extension is in the member’s best interest. The Contractor shall demonstrate to EOHHS that compensation to individuals or entities that conduct utilization management activities is not structured to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any member. The Contractor shall define service authorization in a manner that at least includes an enrollee’s request for the provision of services as required by 42 C.F.R. CFR § 431.210. Contractor must maintain written policies and procedures that cover the language and format of notices of adverse actions: •  Written notice must be translated for individuals who speak prevalent non-English languages, as defined by the State per 42 C.F.R. CFR § 438.10 (c). •  Notice must include language clarifying that oral interpretation is available for all languages and how to access it. •  Written material must use easily understood language and format, be available in alternative formats, and in an appropriate manner that takes into consideration of those with special needs. •  Enrollees and potential enrollees must be informed that information is available in all tentative formats and how to access those formats.

Utilization Review. The Contractor agrees to have written utilization review policies and procedures that include protocols for denial of services, prior approval, physician profiling and retrospective review of claims. As part of its utilization review function, the Contractor also agrees to have processes to identify utilization problems and undertake corrective action. As part of this function, the Contractor shall have a structured process for the approval or denial of covered services. This shall include, in the instance of denials, formal written notification to the member and the requesting or treating provider of the denial, its basis and any applicable appeal rights and procedures. The Contractor shall provide standard authorization decisions within fourteen (14) calendar days of the request for authorization unless the member requests an extension, or the Contractor justifies a need for additional information and the Contractor can demonstrate how the extension is in the member’s interest. If there is a fourteen (14) day extension, the Contractor will comply with all requirements as specified in 42 CFR 438.404(c). The Contractor is permitted to conduct utilization review and place appropriate limits on services while supporting member with ongoing or chronic conditions so long as services are authorized in a manner that reflects the member’s ongoing needs for such services and supports. The Contractor must make an expedited service authorization decision and provide notice as expeditiously as the enrollee’s health condition requires and no later than seventy-two (72) hours after receipt of the request for service for cases in which a provider indicates, or the Contractor determines that following the standard authorization timeframe could seriously jeopardize the enrollee's life or health or his/her ability to attain, maintain, or regain maximum function. The Contractor may extend the seventy-two (72) hour expedited authorization by up to fourteen (14) calendar days if the member requests an extension, or if the Contractor can justify a need for the additional time and the extension is in the member’s best interest. The Contractor shall demonstrate to EOHHS that compensation to individuals or entities that conduct utilization management activities is not structured to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any member. The Contractor shall define service authorization in a manner that at least includes an enrollee’s request for the provision of services as required by 42 C.F.R. § 431.210. 431.210 Contractor must maintain written policies and procedures that cover the language and format of notices of adverse actions: • Written notice must be translated for individuals who speak prevalent non-English languages, as defined by the State per 42 C.F.R. § 438.10 (c). • Notice must include language clarifying that oral interpretation is available for all languages and how to access it. • Written material must use easily understood language and format, be available in alternative formats, and in an appropriate manner that takes into consideration of those with special needs. • Enrollees and potential enrollees must be informed that information is available in all tentative formats and how to access those formats.