Authorization or Denial of Covered Services Sample Clauses

Authorization or Denial of Covered Services a. Contractor shall establish written procedures that Contractor follows, and requires Participating Providers and Subcontractors to follow, for the initial and continuing Service Authorization Requests. The procedures must 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 a Health Care Professional who has appropriate clinical expertise in treating the Member’s physical, mental or oral health condition or disease in accordance with 42 CFR 438.210.
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Authorization or Denial of Covered Services a. Contractor shall draft a Service Authorization Handbook that sets forth Contractor’s written policies and procedures that comply with 42 CFR §438.210 and OAR 410-141-3225 to ensure consistent application of review criteria for authorization decisions. Contractor shall ensure processes allow for consultation with a requesting Provider for medical services when necessary and that processes are in place for both initial and continuing Service Authorization Requests. Such policies and procedures must include, without limitation: (i) those procedures that must be followed in order to obtain initial and continuing Service Authorizations, and (ii) the requirement 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 a Health Care Professional who has appropriate clinical expertise in treating the Member’s physical, behavioral, or Oral Health condition or disease. Contractor must require its Participating Providers and Subcontractors to adhere to the policies and procedures set forth in the Service Authorization Handbook.
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Authorization or Denial of Covered Services a. Contractor shall establish and adhere todraft a Service Authorization Handbook that sets forth Contractor’s written policies and procedures that comply with 42 CFR §438.210 and OAR 410-141-3225 to ensure consistent application of review criteria for authorization decisions. Contractor shall ensure processes allow for consultation with a requesting Provider for medical services when necessary and that processes are in place for both the initial and continuing Service Authorization Requests. Contractor shall require its Participating Providers and Subcontractors to adhere to establishedSuch policies for Service Authorization Requests. Theand procedures must requireinclude, without limitation: (i) those procedures that must be followed in order to obtain initial and continuing Service Authorizations, and (ii) the requirement 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 a Health Care Professional who has appropriate clinical expertise in treating the Member’s physical, mentalbehavioral, or oral healthOral Health condition or disease in accordance with 42 CFR §438.210. b. Contractor maymust require Membersits Participating Providers and Subcontractors to obtain authorization Contract # (XXXXXX) CCO 2.0 Contract Template Exhibit B – Statement of Work – Part 2 - Covered and Non-Covered Services Page 26 of 358 for Covered Services from Contractor, except to the extent Prioradhere to the policies and procedures set forth in the Service Authorization is prohibited by OHP rules or elsewhere in this ContractHandbook.
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Authorization or Denial of Covered Services 
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Related to Authorization or Denial of Covered Services

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