Common use of Benefits Management Program Clause in Contracts

Benefits Management Program. The Benefits Management Program applies utilization management and case management principles to assist Members and providers in identifying the most appropriate and cost-effective way to use the Benefits provided under this health plan. The Benefits Management Program includes prior authorization requirements for inpatient admissions, selected inpatient and outpatient services, office-administered injectable drugs, and home-infusion-administered drugs, as well as Prior authorization allows the Member and provider to verify with Blue Shield or Blue Shield’s MHSA that (1) the proposed services are a Benefit of the Member’s plan, (2) the proposed services are Medically Necessary, and (3) the proposed setting is clinically appropriate. The prior authorization process also informs the Member and provider when Benefits are limited to services rendered by Participating Providers or MHSA Participating Providers (See the Summary of Benefits). A decision will be made on all requests for prior authorization within five business days from receipt of the request. The treating provider will be notified of the decision within 24 hours and written notice will be sent to the Member and provider within two business days of the decision. For urgent services when the routine decision making process might seriously jeopardize the life or health of a Member or when the Member is experiencing severe pain, a decision will be rendered as soon as possible to accommodate the Member’s condition, not to exceed 72 hours from receipt of the request. (See the Outpatient Prescription Drug Benefits section for specific information about prior authorization for outpatient prescription drugs). If prior authorization was not obtained, and services provided to the Member are determined not to be a Benefit of the plan or were not medically necessary, coverage will be denied. Prior authorization is required for radiological and nuclear imaging procedures. The Member or provider should call ▇-▇▇▇-▇▇▇-▇▇▇▇ for prior authorization of the following radiological and nuclear imaging procedures when performed within California on an outpatient, non-emergency basis:

Benefits Management Program. The Benefits Management Program applies utilization management man- agement and case management principles to assist Members and providers in identifying the most appropriate and cost-cost- effective way to use the Benefits provided under this health planPlan. The Benefits Management Program includes prior authorization authori- zation requirements for inpatient Inpatient admissions, selected inpatient Inpa- tient and outpatient servicesOutpatient Services, office-administered injectable drugs, and home-home infusion-administered drugs, as well as emergency admission notification, and Inpatient utilization management. The program also includes Member services such as, discharge planning, case management and pallia- tive care Services. The following sections outline the requirements of the Ben- efits Management Program. PRIOR AUTHORIZATION Prior authorization allows the Member and provider to verify veri- fy with Blue Shield or Blue Shield’s MHSA that (1) the proposed services are a Benefit of the Member’s plan, Plan; (2) the proposed services Services are Medically Necessary, and (3) the proposed setting is clinically appropriate. The prior authorization authori- zation process also informs the Member and provider when Benefits are limited to services Services rendered by Participating Providers or MHSA Participating Providers (See the Summary Sum- ▇▇▇▇ of Benefits). A decision will be made on all requests for prior authorization authoriza- tion within five business days from receipt of the request. The treating provider will be notified of the decision within 24 hours and written notice will be sent to the Member and provider within two business days of the decision. For urgent services ur- gent Services when the routine decision making process might seriously jeopardize the life or health of a Member or when the Member is experiencing severe pain, a decision will be rendered as soon as possible to accommodate the Member’s condition, not to exceed 72 hours from receipt of the request. (See the Outpatient Prescription Drug Benefits section for specific information about prior authorization for outpatient prescription drugs). If prior authorization was is not obtained, and services provided to the Member are determined not to be a Benefit of the plan or were not medically necessaryPlan, coverage will be denied. Prior authorization is required for radiological and nuclear imaging procedures. The Member or provider should call ▇-- ▇▇▇-▇▇▇-▇▇▇▇ for prior authorization of the following radiological ra- diological and nuclear imaging procedures when performed within California on an outpatientOutpatient, non-emergency nonemergency basis: