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 emergency admission notification, and inpatient utilization management. The program also includes Member services such as, discharge planning, case management and, palliative care services. The “Prior Authorization List” is a list of medical services and drugs that require prior authorization. Members are encouraged to work with their providers to obtain prior authorization. Members and providers may call Customer Service at the number provided on the back page of this Evidence of Coverage to inquire about the need for prior authorization. Providers may also access the Prior Authorization List on the provider website. The following sections outline the Member’s responsibilities under the Benefits Management Program. The Benefits Management Program applies to all Members. used to authorize or deny health care services under the plan. Blue Shield has completed documentation of this process as required under Section 1363.5 of the California Health and Safety Code. The document describing Blue Shield’s Utilization Management Program is available online at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ or Members may call the Customer Service Department at the number provided on the back Prior authorization allows the Member and provider to verify with Blue Shield 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 a Participating Provider (See the Summary of Benefits).
Appears in 1 contract
Sources: Health Service Agreement
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 emergency admission notification, and inpatient utilization management. The program also includes Member services such as, discharge planning, case management and, palliative care services. The “Prior Authorization List” is a list of medical services and drugs that require prior authorization. Members are encouraged to work with their providers to obtain prior authorization. Members and providers may call Customer Service at the number provided on the back page of this Evidence of Coverage to inquire about the need for prior authorization. Providers may also access the Prior Authorization List on the provider website. The following sections outline the Member’s responsibilities under the Benefits Management Program. The Benefits Management Program applies to all Members. used to authorize or deny health care services under the plan. Blue Shield has completed documentation of this process as required under Section 1363.5 of the California Health and Safety Code. The document describing Blue Shield’s Utilization Management Program is available online at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ or Members may call the Customer Service Department at the number provided on the back Prior authorization allows the Member and provider to verify with Blue Shield 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 a Participating Provider (See the Summary of Benefits).. The Member or provider should call Customer Service at the number provided on the back page of this Evidence of Coverage for prior authorization of non-emergency medical Hospital admissions and all medical services and drugs included in the Prior Authorization List (except for radiological and nuclear imaging procedures). Prior authorization for radiological and nuclear imaging procedures and Mental Health Services is addressed separately in the following Prior Authorization for Radiological and Nuclear Imaging Procedures and Prior Authorization for Mental Health and Substance Abuse Hospital Admissions and Non-routine Outpatient Services sections. 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). Failure to obtain prior authorization from Blue Shield may increase the Member’s share of the cost for Covered Services or may result in non- payment or denial of coverage by Blue Shield. 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:
Appears in 1 contract