Common use of Failure to Obtain Prior Authorization Clause in Contracts

Failure to Obtain Prior Authorization. The Insured’s Physician must initiate all requests for Prior Authorization. If a Physician or Insured fails to follow the Plan’s procedures for filing a request for Prior Authorization (Pre-Service Claim), the Insured shall be notified of the failure and the proper procedures to be followed in order to obtain Prior Authorization. The Insured’s request for Prior Authorization must be received by an employee or by the department of the Plan customarily responsible for handling benefit matters. The original request must specifically name the Insured, the specific medical condition or symptom and the specific treatment, service or product for which approval is requested. The Insured notification of correct Prior Authorization procedures from the Plan shall be provided as soon as possible, but not later than five (5) days (twenty-four (24) hours in the case of an Urgent Care Claim) following the Plan’s receipt of the Insured’s original request. Notification by SHL may be oral unless specifically requested in writing by the Insured.