Common use of POLICIES AND PROCEDURES FOR SERVICE AUTHORIZATIONS AND PROCESSING REQUESTS Clause in Contracts

POLICIES AND PROCEDURES FOR SERVICE AUTHORIZATIONS AND PROCESSING REQUESTS. The TPA/HCO and its subcontractors shall have and comply with written policies and procedures in processing requests for initial and continuing authorization of services. These procedures shall guarantee the consistent application of review criteria for authorization decisions and consultation with the requesting provider, if necessary. Any decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested, shall be made by a health care professional who has appropriate clinical expertise in treating the enrollee’s condition or disease. The TPA/HCO shall notify the requesting provider and give the enrollee written notice of any decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested; provided, however, that such notice to the enrollee shall be sent whenever the service received by the enrollee was limited, in whole or in part. Although notice to the provider need not be in writing, the enrollee’s written notice shall meet the following requirements:

POLICIES AND PROCEDURES FOR SERVICE AUTHORIZATIONS AND PROCESSING REQUESTS. The TPA/HCO INSURER and its subcontractors shall have in place and comply with written policies and procedures in for processing requests for initial and continuing authorization of services. These The procedures shall guarantee ensure the consistent application of review criteria for authorization decisions and consultation with the requesting provider, if necessaryprovider when appropriate. Any decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested, shall be made by a health care professional who has appropriate clinical expertise in treating the enrollee’s condition or disease. The TPA/HCO INSURER shall notify the requesting provider and give the enrollee written notice of any decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested; provided, however, that such notice to the enrollee shall be sent whenever the service received by the enrollee was limited, in whole or in part. Although notice to the provider need not be in writing, the enrollee’s written notice shall meet the following requirementsrequirements set forth: