Common use of General Prior Authorization Requirements Clause in Contracts

General Prior Authorization Requirements. If the PH-MCO wishes to require Prior Authorization of any services, the PH-MCO must establish and maintain written policies and procedures which must have advance written approval by the Department. In addition, the PH-MCO must include a list and scope of services for referral and Prior Authorization, which must be included in the PH-MCO's Provider manual and Member handbook. The PH-MCO must receive advance written approval of the list and scope of services to be referred or prior authorized by the Department as outlined in Exhibit H, Prior Authorization Guidelines for Participating Managed Care Organizations in the HealthChoices Program, and Exhibit M(1), Quality Management and Utilization Management Program Requirements. The Department will consider Prior Authorization policies and procedures approved under previous HealthChoices agreements approved under this Agreement. The PH-MCO’s submission of new or revised policies and procedures for PARP review and approval shall not act to void any existing, previously approved policies and procedures. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the PARP approves the new or revised version. The Department may subject Prior Authorization Denials issued under unapproved Prior Authorization policies to Retrospective Review and reversal and may impose sanctions and/or require corrective action plans in the event that the PH-MCO improperly implements any Prior Authorization policy or procedure or implements such policy or procedure without Department approval. When the PH-MCO denies a request for services, the PH-MCO must issue a written notice of denial using the appropriate notice outlined in templates N(1), N(2), N(3), and N(7) which are available in Docushare. In addition, the PH-MCO must make the notice available in accessible formats for individuals with visual impairments and for persons with limited English proficiency. If the PH-MCO receives a request from the Member, prior to the end of the required period of advance notice, for a translated and/or accessible version of the notice of denial, the required period of advance notice will begin anew as of the date that PH-MCO mails the translated and/or accessible notice of denial to the Member. For Children in Substitute Care, the PH-MCO must send notices to the County Children and Youth Agency with legal custody of the child or to the court-authorized juvenile probation office with primary supervision of a juvenile provided the PH-MCO knows that the child is in substitute care and the address of the legal custodian of the child. The Department will use its best efforts to review and provide feedback to the PH-MCO (e.g., written approval, request for corrective action plan, denial, etc.) within sixty (60) days from the date the Department receives the request for review. For minor updates to existing approved Prior Authorization plans, the Department will use its best efforts to review updates within forty-five

General Prior Authorization Requirements. The PH-MCO is financially responsible for the provision of Emergency Services without regard to Prior Authorization or the emergency care Provider's contractual relationship with the PH- MCO. If the PH-MCO wishes to require Prior Authorization of any servicesservices which are not required to be prior authorized under the MA FFS Program, the PH-MCO must establish and maintain written policies and procedures which must have advance written approval by the Department. In addition, the PH-MCO must include a list and scope of services for referral and Prior Authorization, which must be included in the PH-MCO's Provider manual and Member handbook. The PH-MCO MCOs must receive advance written approval of the list and scope of services to be referred or prior authorized by the Department as outlined in Exhibit HH of this Agreement, Prior Authorization Guidelines for Participating Managed Care Organizations in the HealthChoices Program, and Exhibit M(1)) of this Agreement, Quality Management and Utilization Management Program Requirements. The Department will consider Prior Authorization policies and procedures approved under previous HealthChoices agreements contracts will be considered approved under this Agreement. The PH-MCO’s submission of new or revised policies and procedures for PARP Prior Authorization Review Panel (PARP) review and approval shall not act to void any existing, previously approved existing policies and proceduresprocedures that were already prior approved for operation in a HealthChoices Zone. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the PARP approves the new or revised versionversion thereof. The Department may subject PH-MCO must not implement Prior Authorization policies without having sought and obtained advance written approval by the Department. Denials issued under unapproved Prior Authorization policies may be subject to Retrospective Review and reversal and may at the Department’s sole discretion. The Department may, at its discretion, impose sanctions and/or require corrective action plans in the event that the PH-MCO improperly implements any Prior Authorization policy or procedure or implements such policy or procedure without Department approvalprocedure. When the PH-MCO denies a request for services, the PH-MCO must issue a written notice of denial using the appropriate notice outlined in templates Exhibits N(1), N(2), N(3)(N)3, and N(7) which are available in Docushareof this Agreement. In addition, the PH-MCO notice must make the notice be available in accessible formats for individuals with visual impairments and for persons with limited English proficiency. If If, pursuant to the required taglines in all notices of denial, the PH-MCO receives a request from the Member, prior to the end of the required period of advance notice, for a translated and/or accessible alternate version of the notice of denial, the required period of advance notice will begin anew as of the date that PH-MCO mails the translated and/or accessible alternate notice of denial to the Member. For Children in Substitute Care, the PH-MCO notices must send notices be sent to the County Children and Youth Agency with legal custody of the a child or to the court-authorized juvenile probation office with primary supervision of a juvenile provided the PH-MCO knows that the child is in substitute care and the address of the legal custodian of the child. The Department will use its best efforts to review and provide feedback to the PH-MCO (e.g., written approval, request for corrective action plan, denial, etc.) within sixty (60) days from the date the Department receives the request for reviewreview from the PH- MCO. For minor updates to existing approved Prior Authorization plans, the Department will use its best efforts to review updates within forty-fivefive (45) days from the date the Department receives the request for review from the PH-MCO. The PH-MCO may waive the Prior Authorization requirements for services which are required by the Department to be Prior Authorized.

General Prior Authorization Requirements. The CHC-MCO may require Prior Authorization for services that require Prior Authorization in the FFS Program. If the PHCHC-MCO wishes to require Prior Authorization of any servicesAuthorization, the PHCHC-MCO must establish and maintain written policies and procedures which must have advance written approval by from the Department. In addition, the PHCHC-MCO must include submit a list and scope of services for referral and Prior Authorization, which must be included in the PH-MCO's Provider manual Authorization for Department review and Member handbook. The PH-MCO must receive advance prior written approval of the list and scope of services to be referred or prior authorized by the Department as outlined in Exhibit HG, Prior Authorization Guidelines for Participating Managed Care Organizations in the HealthChoices CHC Program, and Exhibit M(1K(1), Quality Management and Utilization Management Program Requirements. The Department will consider Prior Authorization policies and procedures approved under previous HealthChoices agreements approved under this Agreement. The PH-MCO’s submission of new or revised policies and procedures for PARP review and approval shall not act to void any existing, previously approved policies and procedures. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the PARP approves the new or revised version. The Department may subject Prior Authorization Denials issued under unapproved Prior Authorization policies to Retrospective Review and reversal and may impose sanctions and/or require corrective action plans in the event that the PH-MCO improperly implements any Prior Authorization policy or procedure or implements such policy or procedure without Department approval. When the PH-MCO denies a request for services, the PH-MCO must issue a written notice of denial using the appropriate notice outlined in templates N(1), N(2), N(3), and N(7) which are available in Docushare. In addition, the PH-MCO must make the notice available in accessible formats for individuals with visual impairments and for persons with limited English proficiency. If the PH-MCO receives a request from the Member, prior to the end of the required period of advance notice, for a translated and/or accessible version of the notice of denial, the required period of advance notice will begin anew as of the date that PH-MCO mails the translated and/or accessible notice of denial to the Member. For Children in Substitute Care, the PH-MCO must send notices to the County Children and Youth Agency with legal custody of the child or to the court-authorized juvenile probation office with primary supervision of a juvenile provided the PH-MCO knows that the child is in substitute care and the address of the legal custodian of the child. The Department will use its best efforts to review and provide feedback to the PHCHC-MCO (e.g., on requests for written approval, request for corrective action planplans, denialor denials, etc.) within sixty (60) days from the date the Department receives the request for review. For minor updates to existing approved Prior Authorization plans, the Department will use its best efforts to review updates within forty-fivefive (45) days from the date the Department receives the request. The Department may subject Prior Authorization Denials issued under unapproved Prior Authorization policies to Retrospective Review and reversal and may impose sanctions and require corrective action plans in the event that the CHC-MCO improperly implements a Prior Authorization policy or procedure or implements such policy or procedure without Departmentapproval. When the CHC-MCO denies a request for services, the CHC-MCO must issue a written notice of denial using the appropriate notice outlined in templates L(1), L(2), L(3), and L(7). In addition, the CHC-MCO must make the notice available in accessible formats for individuals with visual impairments and for persons with LEP. If the CHC-MCO receives a request from the Participant, prior to the end of the required period of advance notice, for a translated and/or accessible version of the notice of denial, the required period of advance notice will begin anew as of the date that CHC- MCO mails the translated and/or accessible notice of denial to the Participant. The CHC-MCO may not require prior authorization of Medicare services for Dual Eligible Participants. If coverage of the service is denied by Medicare, the CHC-MCO may require Prior Authorization if such authorization is required under the CHC-MCO’s approved Prior Authorization policies and procedures. If the CHC-MCO does not require Prior Authorization of the services, the CHC-MCO will approve the service. Service Coordinators are required to work with the Participant’s Medicare plan to obtain expeditious decision-making and communication of decisions.

General Prior Authorization Requirements. ‌ If the PH-MCO wishes to require Prior Authorization of any services, the PH-MCO must establish and maintain written policies and procedures which must have advance written approval by the Department. In addition, the PH-MCO must include a list and scope of services for referral and Prior Authorization, which must be included in the PH-MCO's Provider manual and Member handbook. The PH-MCO must receive advance written approval of the list and scope of services to be referred or prior authorized by the Department as outlined in Exhibit H, Prior Authorization Guidelines for Participating Managed Care Organizations in the HealthChoices Program, and Exhibit M(1), Quality Management and Utilization Management Program Requirements. The Department will consider Prior Authorization policies and procedures approved under previous HealthChoices agreements approved under this Agreement. The PH-MCO’s submission of new or revised policies and procedures for PARP review and approval shall not act to void any existing, previously approved policies and procedures. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the PARP approves the new or revised version. The Department may subject Prior Authorization Denials issued under unapproved Prior Authorization policies to Retrospective Review and reversal and may impose sanctions and/or require corrective action plans in the event that the PH-MCO improperly implements any Prior Authorization policy or procedure or implements such policy or procedure without Department approval. When the PH-MCO denies a request for services, the PH-MCO must issue a written notice of denial using the appropriate notice outlined in templates N(1), N(2), N(3), and N(7) which are available in Docushare. In addition, the PH-MCO must make the notice available in accessible formats for individuals with visual impairments and for persons with limited English proficiency. If the PH-MCO receives a request from the Member, prior to the end of the required period of advance notice, for a translated and/or accessible version of the notice of denial, the required period of advance notice will begin anew as of the date that PH-MCO mails the translated and/or accessible notice of denial to the Member. For Children in Substitute Care, the PH-MCO must send notices to the County Children and Youth Agency with legal custody of the child or to the court-authorized juvenile probation office with primary supervision of a juvenile provided the PH-MCO knows that the child is in substitute care and the address of the legal custodian of the child. The Department will use its best efforts to review and provide feedback to the PH-MCO (e.g., written approval, request for corrective action plan, denial, etc.) within sixty (60) days from the date the Department receives the request for review. For minor updates to existing approved Prior Authorization plans, the Department will use its best efforts to review updates within forty-five

General Prior Authorization Requirements. ‌ If the PH-MCO wishes to require Prior Authorization of any services, the PH-MCO must establish and maintain written policies and procedures which must have advance written approval by the Department. In addition, the PH-MCO must include a list and scope of services for referral and Prior Authorization, which must be included in the PH-MCO's Provider manual and Member handbook. The PH-MCO must receive advance written approval of the list and scope of services to be referred or prior authorized by the Department as outlined in Exhibit H, Prior Authorization Guidelines for Participating Managed Care Organizations in the HealthChoices Program, and Exhibit M(1), Quality Management and Utilization Management Program Requirements. The Department will consider Prior Authorization policies and procedures approved under previous HealthChoices agreements approved under this Agreement. The PH-MCO’s submission of new or revised policies and procedures for PARP review and approval shall not act to void any existing, previously approved policies and procedures. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the PARP approves the new or revised version. The Department may subject Prior Authorization Denials issued under unapproved Prior Authorization policies to Retrospective Review and reversal and may impose sanctions and/or require corrective action plans in the event that the PH-MCO improperly implements any Prior Authorization policy or procedure or implements such policy or procedure without Department approval. When the PH-MCO denies a request for services, the PH-MCO must issue a written notice of denial using the appropriate notice outlined in templates N(1), N(2), N(3)(N)3, and N(7) which are available in Docusharefound on the HealthChoices Intranet site. In addition, the PH-MCO must make the notice available in accessible formats for individuals with visual impairments and for persons with limited English proficiency. If the PH-MCO receives a request from the Member, prior to the end of the required period of advance notice, for a translated and/or accessible version of the notice of denial, the required period of advance notice will begin anew as of the date that PH-MCO mails the translated and/or accessible notice of denial to the Member. For Children in Substitute Care, the PH-MCO must send notices to the County Children and Youth Agency with legal custody of the child or to the court-authorized juvenile probation office with primary supervision of a juvenile provided the PH-MCO knows that the child is in substitute care and the address of the legal custodian of the child. The Department will use its best efforts to review and provide feedback to the PH-MCO (e.g., written approval, request for corrective action plan, denial, etc.) within sixty (60) days from the date the Department receives the request for review. For minor updates to existing approved Prior Authorization plans, the Department will use its best efforts to review updates within fortyforty- five (45) days from the date the Department receives the request for review. The PH-fiveMCO may waive the Prior Authorization requirements for services which are required by the Department to be Prior Authorized.

General Prior Authorization Requirements. ‌ The CHC-MCO is financially responsible for the provision of Emergency Services without regard to Prior Authorization or the emergency care Provider's contractual relationship with the CHC- MCO.‌ If the PHCHC-MCO wishes to require Prior Authorization of any services, the PHCHC-MCO must establish and maintain written policies and procedures which must have advance written approval by the Department. In addition, the PHCHC-MCO must include a list and scope of services for referral and Prior Authorization, which must be included in the PHCHC-MCO's Provider manual and Member Participant handbook. The PHCHC-MCO must receive advance written approval of the list and scope of services to be referred or prior authorized by the Department as outlined in Exhibit H, Prior Authorization Guidelines for Participating Managed Care Organizations in the Community HealthChoices Program, and Exhibit M(1), Quality Management and Utilization Management Program Requirements. The Department will consider Prior Authorization policies and procedures approved under previous Community HealthChoices agreements approved under this Agreementagreement. The PHCHC-MCO’s submission of new or revised policies and procedures for PARP review and approval shall not act to void any existing, previously approved policies and procedures. Unless otherwise required by law, the PHCHC-MCO may must continue to operate under such existing policies and procedures until such time as the PARP approves the new or revised version. version.‌ The Department may subject Prior Authorization Denials issued under unapproved Prior Authorization policies to Retrospective Review and reversal and may impose sanctions and/or require corrective action plans in the event that the PHCHC-MCO improperly implements any Prior Authorization policy or procedure or implements such policy or procedure without Department approval. approval.‌ When the PHCHC-MCO denies a request for services, the PHCHC-MCO must issue a written notice of denial using the appropriate notice outlined in templates N(1), N(2), N(3)(N)3, and N(7) which are available in Docusharefound on the Intranet site supporting CHC. In addition, the PHCHC-MCO must make the notice available in accessible formats for individuals with visual impairments and for persons with limited English proficiency. If the PHCHC-MCO receives a request from the MemberParticipant, prior to the end of the required period of advance notice, for a translated and/or accessible version of the notice of denial, the required period of advance notice will begin anew as of the date that PHCHC-MCO mails the translated and/or accessible notice of denial to the Member. Participant.‌ For Children in Substitute Care, the PHCHC-MCO must send notices to the County Children and Youth Agency with legal custody of the child or to the court-authorized juvenile probation office with primary supervision of a juvenile provided the PHCHC-MCO knows that the child is in substitute care and the address of the legal custodian of the child. child.‌ The Department will use its best efforts to review and provide feedback to the PHCHC-MCO (e.g., written approval, request for corrective action plan, denial, etc.) within sixty (60) days from the date the Department receives the request for review. For minor updates to existing approved Prior Authorization plans, the Department will use its best efforts to review updates within forty-fiveforty- five‌

General Prior Authorization Requirements. If the PH-MCO wishes to require Prior Authorization of any services, the PH-MCO must establish and maintain written policies and procedures which must have advance written approval by the Department. In addition, the PH-MCO must include a list and scope of services for referral and Prior Authorization, which must be included in the PH-MCO's Provider manual and Member handbook. The PH-MCO must receive advance written approval of the list and scope of services to be referred or prior authorized by the Department as outlined in Exhibit H, Prior Authorization Guidelines for Participating Managed Care Organizations in the HealthChoices Program, and Exhibit M(1), Quality Management, Utilization Management and Utilization Management Quality Improvement Program Requirements. The Department will consider Prior Authorization policies and procedures approved under previous HealthChoices agreements approved under this Agreement. The PH-MCO’s submission of new or revised policies and procedures for PARP review and approval shall not act to void any existing, previously approved policies and procedures. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the PARP approves the new or revised version. The Department may subject Prior Authorization Denials issued under unapproved Prior Authorization policies to Retrospective Review and reversal and may impose sanctions and/or require corrective action plans in the event that the PH-MCO improperly implements any Prior Authorization policy or procedure or implements such policy or procedure without Department approval. When the PH-MCO denies a request for services, the PH-MCO must issue a written notice of denial using the appropriate notice outlined in templates N(1), N(2), N(3), and N(7) which are available in Docushare. In addition, the PH-MCO must make the notice available in accessible formats for individuals with visual impairments and for persons with limited English proficiency. If the PH-MCO receives a request from the Member, prior to the end of the required period of advance notice, for a translated and/or accessible version of the notice of denial, the required period of advance notice will begin anew as of the date that PH-MCO mails the translated and/or accessible notice of denial to the Member. For Children in Substitute Care, the PH-MCO must send notices to the County Children and Youth Agency with legal custody of the child or to the court-authorized juvenile probation office with primary supervision of a juvenile provided the PH-MCO knows that the child is in substitute care and the address of the legal custodian of the child. The Department will use its best efforts to review and provide feedback to the PH-MCO (e.g., written approval, request for corrective action plan, denial, etc.) within sixty (60) days from the date the Department receives the request for review. For minor updates to existing approved Prior Authorization plans, the Department will use its best efforts to review updates within forty-five

General Prior Authorization Requirements. If the PH-MCO wishes to require Prior Authorization of any services, the PH-MCO must establish and maintain written policies and procedures which must have advance written approval by the Department. In addition, the PH-MCO must include a list and scope of services for referral and Prior Authorization, which must be included in the PH-MCO's Provider manual and Member handbook. The PH-MCO must receive advance written approval of the list and scope of services to be referred or prior authorized by the Department as outlined in Exhibit H, Prior Authorization Guidelines for Participating Managed Care Organizations in the HealthChoices Program, and Exhibit M(1), Quality Management and Utilization Management Program Requirements. The Department will consider Prior Authorization policies and procedures approved under previous HealthChoices agreements approved under this Agreement. The PH-MCO’s 's submission of new or revised policies and procedures for PARP review and approval shall not act to void any existing, previously approved policies and procedures. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the PARP approves the new or revised version. The Department may subject Prior Authorization Denials issued under unapproved Prior Authorization policies to Retrospective Review and reversal and may impose sanctions and/or require corrective action plans in the event that the PH-MCO improperly implements any Prior Authorization policy or procedure or implements such policy or procedure without Department approval. When the PH-MCO denies a request for services, the PH-MCO must issue a written notice of denial using the appropriate notice outlined in templates N(1), N(2), N(3), and N(7) which are available in Docushare. In addition, the PH-MCO must make the notice available in accessible formats for individuals with visual impairments and for persons with limited English proficiency. If the PH-MCO receives a request from the Member, prior to the end of the required period of advance notice, for a translated and/or accessible version of the notice of denial, the required period of advance notice will begin anew as of the date that PH-MCO mails the translated and/or accessible notice of denial to the Member. For Children in Substitute Care, the PH-MCO must send notices to the County Children and Youth Agency with legal custody of the child or to the court-authorized juvenile probation office with primary supervision of a juvenile provided the PH-MCO knows that the child is in substitute care and the address of the legal custodian of the child. The Department will use its best efforts to review and provide feedback to the PH-MCO (e.g., written approval, request for corrective action plan, denial, etc.) within sixty (60) days from the date the Department receives the request for review. For minor updates to existing approved Prior Authorization plans, the Department will use its best efforts to review updates within forty-five

General Prior Authorization Requirements. If the PH-MCO wishes to require Prior Authorization of any services, the PH-MCO must establish and maintain written policies and procedures which must have advance written approval by the Department. In addition, the PH-MCO must include a list and scope of services for referral and Prior Authorization, which must be included in the PH-MCO's Provider manual and Member handbook. The PH-MCO must receive advance written approval of the list and scope of services to be referred or prior authorized by the Department as outlined in Exhibit H, Prior Authorization Guidelines for Participating Managed Care Organizations in the HealthChoices Program, and Exhibit M(1), Quality Management and Utilization Management Program Requirements. The Department will consider Prior Authorization policies and procedures approved under previous HealthChoices agreements approved under this Agreement. The PH-MCO’s submission of new or revised policies and procedures for PARP review and approval shall not act to void any existing, previously approved policies and procedures. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the PARP approves the new or revised version. The Department may subject Prior Authorization Denials issued under unapproved Prior Authorization policies to Retrospective Review and reversal and may impose sanctions and/or require corrective action plans in the event that the PH-MCO improperly implements any Prior Authorization policy or procedure or implements such policy or procedure without Department approval. When the PH-MCO denies a request for services, the PH-MCO must issue a written notice of denial using the appropriate notice outlined in templates N(1), N(2), N(3)(N)3, and N(7) which are available in Docusharefound on the HealthChoices Intranet site. In addition, the PH-MCO must make the notice available in accessible formats for individuals with visual impairments and for persons with limited English proficiency. If the PH-MCO receives a request from the Member, prior to the end of the required period of advance notice, for a translated and/or accessible version of the notice of denial, the required period of advance notice will begin anew as of the date that PH-MCO mails the translated and/or accessible notice of denial to the Member. For Children in Substitute Care, the PH-MCO must send notices to the County Children and Youth Agency with legal custody of the child or to the court-authorized juvenile probation office with primary supervision of a juvenile provided the PH-MCO knows that the child is in substitute care and the address of the legal custodian of the child. The Department will use its best efforts to review and provide feedback to the PH-MCO (e.g., written approval, request for corrective action plan, denial, etc.) within sixty (60) days from the date the Department receives the request for review. For minor updates to existing approved Prior Authorization plans, the Department will use its best efforts to review updates within fortyforty- five (45) days from the date the Department receives the request for review. The PH-fiveMCO may waive the Prior Authorization requirements for services which are required by the Department to be Prior Authorized.

General Prior Authorization Requirements. ‌ The PH-MCO is financially responsible for the provision of Emergency Services without regard to Prior Authorization or the emergency care Provider's contractual relationship with the PH- MCO. If the PH-MCO wishes to require Prior Authorization of any services, the PH-MCO must establish and maintain written policies and procedures which must have advance written approval by the Department. In addition, the PH-MCO must include a list and scope of services for referral and Prior Authorization, which must be included in the PH-MCO's Provider manual and Member handbook. The PH-MCO must receive advance written approval of the list and scope of services to be referred or prior authorized by the Department as outlined in Exhibit H, Prior Authorization Guidelines for Participating Managed Care Organizations in the HealthChoices Program, and Exhibit M(1), Quality Management and Utilization Management Program Requirements. The Department will consider Prior Authorization policies and procedures approved under previous HealthChoices agreements approved under this Agreement. The PH-MCO’s submission of new or revised policies and procedures for PARP review and approval shall not act to void any existing, previously approved policies and procedures. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the PARP approves the new or revised version. The Department may subject Prior Authorization Denials issued under unapproved Prior Authorization policies to Retrospective Review and reversal and may impose sanctions and/or require corrective action plans in the event that the PH-MCO improperly implements any Prior Authorization policy or procedure or implements such policy or procedure without Department approval. When the PH-MCO denies a request for services, the PH-MCO must issue a written notice of denial using the appropriate notice outlined in templates N(1), N(2), N(3)(N)3, and N(7) which are available in Docusharefound on the HealthChoices Intranet site. In addition, the PH-MCO must make the notice available in accessible formats for individuals with visual impairments and for persons with limited English proficiency. If the PH-MCO receives a request from the Member, prior to the end of the required period of advance notice, for a translated and/or accessible version of the notice of denial, the required period of advance notice will begin anew as of the date that PH-MCO mails the translated and/or accessible notice of denial to the Member. For Children in Substitute Care, the PH-MCO must send notices to the County Children and Youth Agency with legal custody of the child or to the court-authorized juvenile probation office with primary supervision of a juvenile provided the PH-MCO knows that the child is in substitute care and the address of the legal custodian of the child. The Department will use its best efforts to review and provide feedback to the PH-MCO (e.g., written approval, request for corrective action plan, denial, etc.) within sixty (60) days from the date the Department receives the request for review. For minor updates to existing approved Prior Authorization plans, the Department will use its best efforts to review updates within fortyforty- five (45) days from the date the Department receives the request for review. The PH-fiveMCO may waive the Prior Authorization requirements for services which are required by the Department to be Prior Authorized.

General Prior Authorization Requirements. The Contractor must provide Emergency Services without regard to prior authorization or the emergency care provider's contractual relationship with the Contractor. If the PH-MCO Contractor wishes to require Prior Authorization prior authorization of any servicesservices which are not required to be prior authorized under the MA FFS Program, the PH-MCO Contractor must establish and maintain written policies and procedures which must have advance written approval by the Department. In addition, the PH-MCO Contractor must include a list and scope of services for referral and Prior Authorizationprior authorization, which must be included in the PH-MCOContractor's Provider manual Manual and Member handbookHandbook. The PH-MCO Contractors must receive advance written approval of the list and scope of services to be referred or prior authorized by the Department as outlined in Exhibit HH of this Agreement, Prior Authorization Guidelines for Participating Managed Care Organizations in the HealthChoices Program, and Exhibit M(1)) of this Agreement, Quality Management and Utilization Management Program Requirements. The Department will consider Prior Authorization authorization policies and procedures approved under previous HealthChoices agreements contracts will be considered approved under this Agreement. The PH-MCO’s submission of new or revised policies and procedures for PARP review and approval Contractor shall not act to void any existing, previously approved implement prior authorization policies without having sought and proceduresobtained advance written approval by the Department. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the PARP approves the new or revised version. The Department may subject Prior Authorization Denials issued under unapproved Prior Authorization prior authorization policies may be subject to Retrospective Review retrospective review and reversal and may at the Department's sole discretion. The Department may, at its discretion, impose sanctions and/or require corrective action plans in the event that the PH-MCO Contractor improperly implements any Prior Authorization prior authorization policy or procedure or implements such policy or procedure without Department approval. When the PH-MCO denies a request for services, the PH-MCO must issue a written notice of denial using the appropriate notice outlined in templates N(1), N(2), N(3), and N(7) which are available in Docushare. In addition, the PH-MCO must make the notice available in accessible formats for individuals with visual impairments and for persons with limited English proficiency. If the PH-MCO receives a request from the Member, prior to the end of the required period of advance notice, for a translated and/or accessible version of the notice of denial, the required period of advance notice will begin anew as of the date that PH-MCO mails the translated and/or accessible notice of denial to the Member. For Children in Substitute Care, the PH-MCO must send notices to the County Children and Youth Agency with legal custody of the child or to the court-authorized juvenile probation office with primary supervision of a juvenile provided the PH-MCO knows that the child is in substitute care and the address of the legal custodian of the childprocedure. The Department will use make its best efforts to review and provide feedback to the PH-MCO Contractor (e.g., written approval, request for corrective action plan, denial, etc.) within sixty (60) days from the date the Department receives the request for reviewreview by the Contractor. For minor updates to existing approved Prior Authorization prior authorization plans, the Department will use make its best efforts to review updates within forty-fivefive (45) days from the date the Department receives the request for review by the Contractor. The Contractor is required to process each request for prior authorization of a covered service and ensure that the Member is notified of the decision within two (2) business days of receiving the request. If the Member does not receive written notification of a decision on a request for a covered service or item within twenty-one (21) days of the date the Contractor received the request, the service or item is automatically approved. To satisfy the twenty-one (21) day time period, the Contractor must mail to the Member, the Member's PCP, and the prescribing Provider a notice of partial approval or denial of the request on or before the eighteenth (18th) day from the date the request is received. If the notice is not mailed by the eighteenth (18th) day after the request is received, the request is automatically authorized (i.e., deemed approved). If additional information is needed to review the request, the Contractor must request such information from the appropriate Provider within forty-eight (48) hours of receiving the request for prior authorization of a covered service. If the Contractor requests additional information, the request may be pended for a reasonable time period. However, a prospective utilization review decision must be communicated to the Member within two (2) business days of the receipt of all supporting information reasonably necessary to complete the review. The Contractor may waive the prior authorization requirements for services, which are required by the Department to be prior authorized. If a HCFA determination that an HMO has committed a violation described in paragraph (a) of 42 C.F.R. Chapter IV Subsection 434.67 (Sanctions Against HMOs with Risk Comprehensive Contracts) is affirmed on review of paragraph (d) (Informal Reconsideration), or is not timely contested by the HMO under paragraph (c) (Notice of Sanction), HCFA, based upon this recommendation of the agency, may deny payment for new enrollees of the HMO under Section 1903 (m)(5)(B)(ii) of the Act. Under Subsections 434.22 and 434.42, HCFA's denial of payment for new enrollees automatically results in a denial of agency payments to the HMO for the same enrollees. A new enrollee is an enrollee that applies for enrollment after the effective date as found in 42 C.F.R. Section 434.67(f)(l).

General Prior Authorization Requirements. ‌ The PH-MCO is financially responsible for the provision of Emergency Services without regard to Prior Authorization or the emergency care Provider's contractual relationship with the PH- MCO. If the PH-MCO wishes to require Prior Authorization of any services, the PH-MCO must establish and maintain written policies and procedures which must have advance written approval by the Department. In addition, the PH-MCO must include a list and scope of services for referral and Prior Authorization, which must be included in the PH-MCO's Provider manual and Member handbook. The PH-MCO MCOs must receive advance written approval of the list and scope of services to be referred or prior authorized by the Department as outlined in Exhibit HH of this Agreement, Prior Authorization Guidelines for Participating Managed Care Organizations in the HealthChoices Program, and Exhibit M(1)) of this Agreement, Quality Management and Utilization Management Program Requirements. The Department will consider Prior Authorization policies and procedures approved under previous HealthChoices agreements contracts will be considered approved under this Agreement. The PH-MCO’s submission of new or revised policies and procedures for PARP Prior Authorization Review Panel (PARP) review and approval shall not act to void any existing, previously approved existing policies and proceduresprocedures that were already prior approved for operation in a HealthChoices Zone. Unless otherwise required by law, the PH-MCO may continue to operate under such existing policies and procedures until such time as the PARP approves the new or revised versionversion thereof. The Department may subject PH-MCO must not implement Prior Authorization policies without having sought and obtained advance written approval by the Department. Denials issued under unapproved Prior Authorization policies may be subject to Retrospective Review and reversal and may at the Department’s sole discretion. The Department may, at its discretion, impose sanctions and/or require corrective action plans in the event that the PH-MCO improperly implements any Prior Authorization policy or procedure or implements such policy or procedure without Department approvalprocedure. When the PH-MCO denies a request for services, the PH-MCO must issue a written notice of denial using the appropriate notice outlined in templates Exhibits N(1), N(2), N(3)(N)3, and N(7) which are available in Docushareof this Agreement. In addition, the PH-MCO notice must make the notice be available in accessible formats for individuals with visual impairments and for persons with limited English proficiency. If If, pursuant to the required taglines in all notices of denial, the PH-MCO receives a request from the Member, prior to the end of the required period of advance notice, for a translated and/or accessible alternate version of the notice of denial, the required period of advance notice will begin anew as of the date that PH-MCO mails the translated and/or accessible alternate notice of denial to the Member. For Children in Substitute Care, the PH-MCO notices must send notices be sent to the County Children and Youth Agency with legal custody of the a child or to the court-authorized juvenile probation office with primary supervision of a juvenile provided the PH-MCO knows that the child is in substitute care and the address of the legal custodian of the child. The Department will use its best efforts to review and provide feedback to the PH-MCO (e.g., written approval, request for corrective action plan, denial, etc.) within sixty (60) days from the date the Department receives the request for reviewreview from the PH- MCO. For minor updates to existing approved Prior Authorization plans, the Department will use its best efforts to review updates within forty-fivefive (45) days from the date the Department receives the request for review from the PH-MCO.