Common use of Medical Management Programs Clause in Contracts

Medical Management Programs. The Medical Management Programs are services that can help you coordinate your care and treatment. They include utilization management and care management. Blue Shield uses utilization management to help you and your providers identify the most appropriate and cost-effective way to use the Benefits of this plan. Care management and palliative care can help you access the care you need to manage serious health conditions and complex treatment plans. For written information about Blue Shield’s Utilization Management Program, visit xxxxxxxxxxxx.xxx. Prior authorization Coverage for some Benefits requires pre-approval from Blue Shield. This process is called prior authorization. Prior authorization requests are reviewed for Medical Necessity, available plan Benefits, and clinically appropriate setting. The prior authorization process also identifies Benefits that are only covered from Participating Providers or in a specific clinical setting. If you see a Participating Provider, your provider must obtain prior authorization when required. When prior authorization is required but not obtained, Blue Shield may deny payment to your provider. You are not responsible for Blue Shield’s portion of the Allowable Amount if this occurs, only your Cost Share. If you see a Non-Participating Provider, you or your provider must obtain prior authorization when required. When prior authorization is required but not obtained, and the services provided are determined not to be a Benefit of the plan or Medically Necessary, Blue Shield may deny payment and you will be responsible for all billed charges. You do not need prior authorization for Emergency Services or emergency Hospital admissions at Participating or Non-Participating facilities. For non-emergency inpatient services, your provider should request prior authorization at least five business days before admission. Visit xxxxxxxxxxxx.xxx and click on Prior Authorization List for more details about medical and surgical services and select prescription Drugs that require prior authorization. Prescription Drugs administered by a Health Care Provider Drugs administered by a Health Care Provider in a Physician’s office, an infusion center, the Outpatient Department of a Hospital, or provided at home through a home infusion agency, are covered under the medical benefit and require prior authorization. The prior authorization process for self-administered prescription Drugs available at a retail, specialty, or mail order pharmacy is explained in the Prescription Drug Benefits section. Frequently-utilized services that require prior authorization Benefit Services that require prior authorization Medical and prescription Drug • Surgery • Prescription Drugs administered by a Health Care Provider • Non-emergency inpatient facility services, such as Hospitals and Skilled Nursing Facilities • Non-emergency ambulance services • Routine patient care received while enrolled in a clinical trial • Hospice program enrollment Radiological and nuclear imaging • CT (Computerized Tomography) scan • MRI (Magnetic Resonance Imaging) • MRA (Magnetic Resonance Angiography) • PET (Positron Emission Tomography) scan • Diagnostic cardiac procedure utilizing nuclear medicine Mental Health and Substance Use Disorder • Non-emergency mental health or substance use disorder Hospital admissions, including acute and residential care • Behavioral Health Treatment • Electroconvulsive therapy • Psychological testing • Partial Hospitalization Program • Intensive Outpatient Program • Office-based opioid treatment • Transcranial magnetic stimulation When a decision will be made about your prior authorization request Prior authorization or exception request Time for decision Routine medical and Mental Health and Substance Use Disorder requests Within five business days Expedited medical and Mental Health and Substance Use Disorder requests Within 72 hours Routine prescription Drug requests Within 72 hours Expedited prescription Drug requests Within 24 hours Expedited requests include urgent medical and exigent pharmacy requests. Once the decision is made, your provider will be notified within 24 hours. Written notice will be sent to you and your provider within two business days. While you are in the Hospital (inpatient utilization review) When you are admitted to the Hospital, your stay will be monitored for continued Medical Necessity. If it is no longer Medically Necessary for you to receive an inpatient level of care, Blue Shield will send a written notice to you, your provider, and the Hospital. If you choose to stay in the Hospital past the date indicated in this notice, you will be financially responsible for all inpatient charges after that date. Exceptions to inpatient utilization review include maternity and mastectomy care. For maternity, the minimum length of an inpatient stay is 48 hours for a normal, vaginal delivery and 96 hours for a C-section. The provider and mother together may decide that a shorter length of stay is adequate. For mastectomy, you and your provider determine the Medically Necessary length of stay after the surgery.

Medical Management Programs. The Medical Management Programs are services that can help you coordinate your care and treatment. They include utilization management and care management. Blue Shield uses utilization management to help you and your providers identify the most appropriate and cost-effective way to use the Benefits of this plan. Care management and palliative care can help you access the care you need to manage serious health conditions and complex treatment plans. For written information about Blue Shield’s Utilization Management Program, visit xxxxxxxxxxxx.xxx. Prior authorization Coverage for some Benefits requires pre-approval from Blue Shield. This process is called prior authorization. Prior authorization requests are reviewed for Medical Necessity, available plan Benefits, and clinically appropriate setting. The prior authorization process also identifies Benefits that are only covered from Participating Providers or in a specific clinical setting. If you see a Participating Provider, your provider must obtain prior authorization when required. When prior authorization is required but not obtained, Blue Shield may deny payment to your provider. You are not responsible for Blue Shield’s portion of the Allowable Amount if this occurs, only your Cost Share. If you see a Non-Participating Provider, you or your provider must obtain prior authorization when required. When prior authorization is required but not obtained, and the services provided are determined not to be a Benefit of the plan or Medically Necessary, Blue Shield may deny payment and you will be responsible for all billed charges. You do not need prior authorization for Emergency Services or emergency Hospital admissions at Participating or Non-Participating facilities. For non-emergency inpatient services, your provider should request prior authorization at least five business days before admission. Visit xxxxxxxxxxxx.xxx and click on Prior Authorization List for more details about medical and surgical services and select prescription Drugs that require prior authorization. Prescription Drugs administered by a Health Care Provider Drugs administered by a Health Care Provider in a Physician’s office, an infusion center, the Outpatient Department of a Hospital, or provided at home through a home infusion agency, are covered under the medical benefit and require prior authorization. The prior authorization process for self-administered prescription Drugs available at a retail, specialty, or mail order pharmacy is explained in the Prescription Drug Benefits section. Frequently-utilized services that require prior authorization Benefit Services that require prior authorization Medical and prescription Drug • Surgery • Prescription Drugs administered by a Health Care Provider • Non-emergency inpatient facility services, such as Hospitals and Skilled Nursing Facilities • Non-emergency ambulance services • Routine patient care received while enrolled in a clinical trial • Hospice program enrollment Radiological and nuclear imaging • CT (Computerized Tomography) scan • MRI (Magnetic Resonance Imaging) • MRA (Magnetic Resonance Angiography) • PET (Positron Emission Tomography) scan • Diagnostic cardiac procedure utilizing nuclear medicine Mental Health health and Substance Use Disorder substance use disorder • Non-emergency mental health or substance use disorder Hospital admissions, including acute and residential care • Behavioral Health Treatment • Electroconvulsive therapy • Psychological testing • Partial Hospitalization Program • Intensive Outpatient Program • Office-based opioid treatment • Transcranial magnetic stimulation When a decision will be made about your prior authorization request Prior authorization or exception request Time for decision Routine medical and Mental Health mental health and Substance Use Disorder substance use disorder requests Within five business days Expedited medical and Mental Health mental health and Substance Use Disorder substance use disorder requests Within 72 hours Routine prescription Drug requests Within 72 hours Expedited prescription Drug requests Within 24 hours Expedited requests include urgent medical and exigent pharmacy requests. Once the decision is made, your provider will be notified within 24 hours. Written notice will be sent to you and your provider within two business days. While you are in the Hospital (inpatient utilization review) When you are admitted to the Hospital, your stay will be monitored for continued Medical Necessity. If it is no longer Medically Necessary for you to receive an inpatient level of care, Blue Shield will send a written notice to you, your provider, and the Hospital. If you choose to stay in the Hospital past the date indicated in this notice, you will be financially responsible for all inpatient charges after that date. Exceptions to inpatient utilization review include maternity and mastectomy care. For maternity, the minimum length of an inpatient stay is 48 hours for a normal, vaginal delivery and 96 hours for a C-section. The provider and mother together may decide that a shorter length of stay is adequate. For mastectomy, you and your provider determine the Medically Necessary length of stay after the surgery.

Medical Management Programs. The Medical Management Programs are services that can help you coordinate your care and treatment. They include utilization management and care management. Blue Shield uses utilization management to help you and your providers identify the most appropriate and cost-effective way to use the Benefits of this plan. Care management and palliative care can help you access the care you need to manage serious health conditions and complex treatment plans. For written information about Blue Shield’s Utilization Management Program, visit xxxxxxxxxxxx.xxx. Prior authorization Coverage for some Benefits requires pre-approval from Blue Shield. This process is called prior authorization. Prior authorization requests are reviewed for Medical Necessity, available plan Benefits, and clinically appropriate setting. The prior authorization process also identifies Benefits that are only covered from Participating Providers or in a specific clinical setting. If you see a Participating Provider, your provider must obtain prior authorization when required. When prior authorization is required but not obtained, Blue Shield may deny payment to your provider. You are not responsible for Blue Shield’s portion of the Allowable Amount if this occurs, only your Cost Share. If you see a Non-Participating Provider, you or your provider must obtain prior authorization when required. When prior authorization is required but not obtained, and the services provided are determined not to be a Benefit of the plan or Medically Necessary, Blue Shield may deny payment and you will be responsible for all billed charges. You do not need prior authorization for Emergency Services or emergency Hospital admissions at Participating or Non-Participating facilities. For non-emergency inpatient services, your provider should request prior authorization at least five business days before admission. Visit xxxxxxxxxxxx.xxx and click on Prior Authorization List for more details about medical and surgical services and select prescription Drugs that require prior authorization. Prescription Drugs administered by a Health Care Provider Drugs administered by a Health Care Provider in a Physician’s office, an infusion center, the Outpatient Department of a Hospital, or provided at home through a home infusion agency, are covered under the medical benefit and require prior authorization. The prior authorization process for self-administered prescription Drugs available at a retail, specialty, or mail order pharmacy is explained in the Prescription Drug Benefits section. Frequently-utilized services that require prior authorization Benefit Services that require prior authorization Medical and prescription Drug • Surgery • Prescription Drugs administered by a Health Care Provider • Non-emergency inpatient facility services, such as Hospitals and Skilled Nursing Facilities • Non-emergency ambulance services • Routine patient care received while enrolled in a clinical trial • Hospice program enrollment Radiological and nuclear imaging • CT (Computerized Tomography) scan • MRI (Magnetic Resonance Imaging) • MRA (Magnetic Resonance Angiography) • PET (Positron Emission Tomography) scan • Diagnostic cardiac procedure utilizing nuclear medicine Mental Health health and Substance Use Disorder substance use disorder • Non-emergency mental health or substance use disorder Hospital admissions, including acute and residential care • Behavioral Health Treatment • Electroconvulsive therapy • Psychological testing • Partial Hospitalization Program • Intensive Outpatient Program • Office-based opioid treatment • Transcranial magnetic stimulation When a decision will be made about your prior authorization request Prior authorization or exception request Time for decision Routine medical and Mental Health mental health and Substance Use Disorder substance use disorder requests Within five business days Expedited medical and Mental Health mental health and Substance Use Disorder substance use disorder requests Within 72 hours Routine prescription Drug requests Within 72 hours Expedited prescription Drug requests Within 24 hours Expedited requests include urgent medical and exigent pharmacy requests. Once the decision is made, your provider will be notified within 24 hours. Written notice will be sent to you and your provider within two business days. While you are in the Hospital (inpatient utilization review) When you are admitted to the Hospital, your stay will be monitored for continued Medical Necessity. If it is no longer Medically Necessary for you to receive an inpatient level of care, Blue Shield will send a written notice to you, your provider, and the Hospital. If you choose to stay in the Hospital past the date indicated in this notice, you will be financially responsible for all inpatient charges after that date. Exceptions to inpatient utilization review include maternity and mastectomy care. For maternity, the minimum length of an inpatient stay is 48 hours for a normal, vaginal delivery and 96 hours for a C-section. The provider and mother together may decide that a shorter length of stay is adequate. For mastectomy, you and your provider determine the Medically Necessary length of stay after the surgery.

Medical Management Programs. The Medical Management Programs are services that can help you coordinate your care and treatment. They include utilization management and care management. Blue Shield uses utilization management to help you and your providers identify the most appropriate and cost-effective way to use the Benefits of this plan. Care management and palliative care can help you access the care you need to manage serious health conditions and complex treatment plans. For written information about Blue Shield’s Utilization Management Program, visit xxxxxxxxxxxx.xxx. Prior authorization Coverage for some Benefits requires pre-approval from Blue Shield. This process is called prior authorization. Prior authorization requests are reviewed for Medical Necessity, available plan Benefits, and clinically appropriate setting. The prior authorization process also identifies Benefits that are only covered from Participating Providers or in a specific clinical setting. If you see a Participating Provider, your provider must obtain prior authorization when required. When prior authorization is required but not obtained, Blue Shield may deny payment to your provider. You are not responsible for Blue Shield’s portion of the Allowable Amount if this occurs, only your Cost Share. If you see a Non-Participating Provider, you or your provider must obtain prior authorization when required. When prior authorization is required but not obtained, and the services provided are determined not to be a Benefit of the plan or Medically Necessary, Blue Shield may deny payment and you will be responsible for all billed charges. You do not need prior authorization for Emergency Services or emergency Hospital admissions at Participating or Non-Participating facilities. For non-emergency inpatient services, your provider should request prior authorization at least five business days before admission. Visit xxxxxxxxxxxx.xxx and click on Prior Authorization List for more details about medical and surgical services and select prescription Drugs that require prior authorization. Prescription Drugs administered by a Health Care Provider Drugs administered by a Health Care Provider in a Physician’s office, an infusion center, the Outpatient Department of a Hospital, or provided at home through a home infusion agency, are covered under the medical benefit and require prior authorization. The prior authorization process for self-administered prescription Drugs available at a retail, specialty, or mail order pharmacy is explained in the Prescription Drug Benefits section. Frequently-utilized services that require prior authorization Benefit Services that require prior authorization Medical and prescription Drug •   Surgery • Prescription Drugs administered by a Health Care Provider •  Non-emergency inpatient facility services, such as Hospitals and Skilled Nursing Facilities •  Non-emergency ambulance services •  Routine patient care received while enrolled in a clinical trial •  Hospice program enrollment Radiological and nuclear imaging •    CT (Computerized Tomography) scan • MRI (Magnetic Resonance Imaging) • MRA (Magnetic Resonance Angiography) •  PET (Positron Emission Tomography) scan •  Diagnostic cardiac procedure utilizing nuclear medicine Mental Health health and Substance Use Disorder • substance use disorder   Non-emergency mental health or substance use disorder Hospital admissions, including acute and residential care • Behavioral Health Treatment •  Electroconvulsive therapy •  Psychological testing •  Partial Hospitalization Program •  Intensive Outpatient Program •  Office-based opioid treatment •  Transcranial magnetic stimulation When a decision will be made about your prior authorization request Prior authorization or exception request Time for decision Routine medical and Mental Health mental health and Substance Use Disorder substance use disorder requests Within five business days Expedited medical and Mental Health mental health and Substance Use Disorder substance use disorder requests Within 72 hours Routine prescription Drug requests Within 72 hours Expedited prescription Drug requests Within 24 hours Expedited requests include urgent medical and exigent pharmacy requests. Once the decision is made, your provider will be notified within 24 hours. Written notice will be sent to you and your provider within two business days. While you are in the Hospital (inpatient utilization review) When you are admitted to the Hospital, your stay will be monitored for continued Medical Necessity. If it is no longer Medically Necessary for you to receive an inpatient level of care, Blue Shield will send a written notice to you, your provider, and the Hospital. If you choose to stay in the Hospital past the date indicated in this notice, you will be financially responsible for all inpatient charges after that date. Exceptions to inpatient utilization review include maternity and mastectomy care. For maternity, the minimum length of an inpatient stay is 48 hours for a normal, vaginal delivery and 96 hours for a C-section. The provider and mother together may decide that a shorter length of stay is adequate. For mastectomy, you and your provider determine the Medically Necessary length of stay after the surgery.

Medical Management Programs. The Medical Management Programs are services that can help you coordinate your care and treatment. They include utilization management and care management. Blue Shield uses utilization management to help you and your providers identify the most appropriate and cost-effective way to use the Benefits of this plan. Care management and palliative care can help you access the care you need to manage serious health conditions and complex treatment plans. For written information about Blue Shield’s Utilization Management Program, visit xxxxxxxxxxxx.xxx. Prior authorization Coverage for some Benefits requires pre-approval from Blue Shield. This process is called prior authorization. Prior authorization requests are reviewed for Medical Necessity, available plan Benefits, and clinically appropriate setting. The prior authorization process also identifies Benefits that are only covered from Participating Providers or in a specific clinical setting. If you see a Participating Provider, your provider must obtain prior authorization when required. When prior authorization is required but not obtained, Blue Shield may deny payment to your provider. You are not responsible for Blue Shield’s portion of the Allowable Amount if this occurs, only your Cost Share. If you see a Non-Participating Provider, you or your provider must obtain prior authorization when required. When prior authorization is required but not obtained, and the services provided are determined not to be a Benefit of the plan or Medically Necessary, Blue Shield may deny payment and you will be responsible for all billed charges. You do not need prior authorization for Emergency Services or emergency Hospital admissions at Participating or Non-Participating facilities. For non-emergency inpatient services, your provider should request prior authorization at least five business days before admission. Visit xxxxxxxxxxxx.xxx and click on Prior Authorization List for more details about medical and surgical services and select prescription Drugs that require prior authorization. Prescription Drugs administered by a Health Care Provider Drugs administered by a Health Care Provider in a Physician’s office, an infusion center, the Outpatient Department of a Hospital, or provided at home through a home infusion agency, are covered under the medical benefit and require prior authorization. The prior authorization process for self-administered prescription Drugs available at a retail, specialty, or mail order pharmacy is explained in the Prescription Drug Benefits section. Frequently-utilized services that require prior authorization Benefit Services that require prior authorization Medical and prescription Drug •   Surgery • Prescription Drugs administered by a Health Care Provider •  Non-emergency inpatient facility services, such as Hospitals and Skilled Nursing Facilities •  Non-emergency ambulance services •  Routine patient care received while enrolled in a clinical trial •  Hospice program enrollment Radiological and nuclear imaging •    CT (Computerized Tomography) scan • MRI (Magnetic Resonance Imaging) • MRA (Magnetic Resonance Angiography) •  PET (Positron Emission Tomography) scan •  Diagnostic cardiac procedure utilizing nuclear medicine Mental Health health and Substance Use Disorder • substance use disorder   Non-emergency mental health or substance use disorder Hospital admissions, including acute and residential care • Behavioral Health Treatment •  Electroconvulsive therapy •  Psychological testing •  Partial Hospitalization Program •  Intensive Outpatient Program •  Office-based opioid treatment •  Transcranial magnetic stimulation When a decision will be made about your prior authorization request Prior authorization or exception request Time for decision Routine medical and Mental Health mental health and Substance Use Disorder substance use disorder requests Within five business days Expedited medical and Mental Health mental health and Substance Use Disorder substance use disorder requests Within 72 hours Routine prescription Drug requests Within 72 hours Expedited prescription Drug requests Within 24 hours Expedited requests include urgent medical and exigent pharmacy requests. Once the decision is made, your provider will be notified within 24 hours. Written notice will be sent to you and your provider within two business days. While you are in the Hospital (inpatient utilization review) When you are admitted to the Hospital, your stay will be monitored for continued Medical Necessity. If it is no longer Medically Necessary for you to receive an inpatient level of care, Blue Shield will send a written notice to you, your provider, and the Hospital. If you choose to stay in the Hospital past the date indicated in this notice, you will be financially responsible for all inpatient charges after that date. Exceptions to inpatient utilization review include maternity and mastectomy care. For maternity, the minimum length of an inpatient stay is 48 hours for a normal, vaginal delivery and 96 hours for a C-section. The provider and mother together may decide that a shorter length of stay is adequate. For mastectomy, you and your provider determine the Medically Necessary length of stay after the surgery.

Medical Management Programs. The Medical Management Programs are services that can help you coordinate your care and treatment. They include utilization management and care management. Blue Shield uses utilization management to help you and your providers identify the most appropriate and cost-effective way to use the Benefits of this plan. Care management and palliative care can help you access the care you need to manage serious health conditions and complex treatment plans. For written information about Blue Shield’s Utilization Management Program, visit xxxxxxxxxxxx.xxx. Prior authorization Coverage for some Benefits requires pre-approval from Blue Shield. This process is called prior authorization. Prior authorization requests are reviewed for Medical Necessity, available plan Benefits, and clinically appropriate setting. The prior authorization process also identifies Benefits that are only covered from Participating Providers or in a specific clinical setting. If you see a Participating Provider, your provider must obtain prior authorization when required. When prior authorization is required but not obtained, Blue Shield may deny payment to your provider. You are not responsible for Blue Shield’s portion of the Allowable Amount if this occurs, only your Cost Share. If you see a Non-Participating Provider, you or your provider must obtain prior authorization when required. When prior authorization is required but not obtained, and the services provided are determined not to be a Benefit of the plan or Medically Necessary, Blue Shield may deny payment and you will be responsible for all billed charges. You do not need prior authorization for Emergency Services or emergency Hospital admissions at Participating or Non-Participating facilities. For non-emergency inpatient services, your provider should request prior authorization at least five business days before admission. Visit xxxxxxxxxxxx.xxx and click on Prior Authorization List for more details about medical and surgical services and select prescription Drugs that require prior authorization. Prescription Drugs administered by a Health Care Provider Drugs administered by a Health Care Provider in a Physician’s office, an infusion center, the Outpatient Department of a Hospital, or provided at home through a home infusion agency, are covered under the medical benefit and require prior authorization. The prior authorization process for self-administered prescription Drugs available at a retail, specialty, or mail order pharmacy is explained in the Prescription Drug Benefits section. Frequently-utilized services that require prior authorization Benefit Services that require prior authorization Medical and prescription Drug • Surgery • Prescription Drugs administered by a Health Care Provider • Non-emergency inpatient facility services, such as Hospitals and Skilled Nursing Facilities • Non-emergency ambulance services • Routine patient care received while enrolled in a clinical trial • Hospice program enrollment Radiological and nuclear imaging • CT (Computerized Tomography) scan • MRI (Magnetic Resonance Imaging) • MRA (Magnetic Resonance Angiography) • PET (Positron Emission Tomography) scan • Diagnostic cardiac procedure utilizing nuclear medicine Mental Health and Substance Use Disorder • Non-emergency mental health or substance use disorder Hospital admissions, including acute and residential care • Behavioral Health Treatment • Electroconvulsive therapy • Psychological testing • Partial Hospitalization Program • Intensive Outpatient Program • Office-based opioid treatment • Transcranial magnetic stimulation When a decision will be made about your prior authorization request Prior authorization or exception request Time for decision Routine medical and Mental Health and Substance Use Disorder requests Within five business days Expedited medical and Mental Health and Substance Use Disorder requests Within 72 hours Routine prescription Drug requests Within 72 hours Expedited prescription Drug requests Within 24 hours Expedited requests include urgent medical and exigent pharmacy requests. Once the decision is made, your provider will be notified within 24 hours. Written notice will be sent to you and your provider within two business days. While you are in the Hospital (inpatient utilization review) When you are admitted to the Hospital, your stay will be monitored for continued Medical Necessity. If it is no longer Medically Necessary for you to receive an inpatient level of care, Blue Shield will send a written notice to you, your provider, and the Hospital. If you choose to stay in the Hospital past the date indicated in this notice, you will be financially responsible for all inpatient charges after that date. Exceptions to inpatient utilization review include maternity and mastectomy care. For maternity, the minimum length of an inpatient stay is 48 hours for a normal, vaginal delivery and 96 hours for a C-section. The provider and mother together may decide that a shorter length of stay is adequate. For mastectomy, you and your provider determine the Medically Necessary length of stay after the surgery.