FUNCTIONS AND CAPABILITIES. A. Prior Authorizations. The Contractor shall provide an automated system that includes the following: 1. Enrollee eligibility, utilization, and Care Management information. 2. Edits to ensure enrollee is eligible, provider is eligible, and service is covered. 3. Predefined treatment criteria to aid in adjudicating the requests. 4. Notification to provider of approval or denial including specific reason for denial. 5. Notification to enrollees of any denials or cutbacks of service. 6. Interface with claims processing system for editing and payment.
Appears in 6 contracts
Sources: Contract to Provide Services, Contract to Provide Services, Contract to Provide Services
FUNCTIONS AND CAPABILITIES. A. Prior Authorizations. The Contractor contractor shall provide an automated system that includes the following:
1. Enrollee eligibility, utilization, and Care Management case management information.
2. Edits to ensure enrollee is eligible, provider is eligible, and service is covered.
3. Predefined treatment criteria to aid in adjudicating the requests.
4. Notification to provider of approval or denial including specific reason for denial.
5. Notification to enrollees of any denials or cutbacks of service.
6. Interface with claims processing system for editing and paymentediting.
Appears in 4 contracts
Sources: Agreement to Provide Hmo Services (Amerigroup Corp), Contract to Provide Services (Amerigroup Corp), Contract to Provide Services (Centene Corp)