Prior Authorization Sample Clauses

Prior Authorization. A determination to authorize a Provider’s request, pursuant to services covered in the MississippiCAN Program, to provide a service or course of treatment of a specific duration and scope to a Member prior to the initiation or continuation of the service.
Prior Authorization. Have the ability to require Prior Authorization on medications to ensure appropriate use and to encourage the use of preferred medications.
Prior Authorization. Except for Emergency Services or where prior authorization is not required by the Provider Manual, Providers shall obtain prior authorization for Covered Services in accordance with the Provider Manual. Except where not permitted by Laws or Program Requirements, Health Plan may deny payment for Covered Services where a Provider fails to meet Health Plan’s requirements for prior authorization.
Prior Authorization. This Section explains what Covered Health Care Services require Prior Authorization before you receive these services and how to obtain Prior Authorization. This is not an exhaustive list. Further information can be obtained through your PCP or at our website at Before you are admitted as an Inpatient to a Hospital, Skilled Nursing Facility or other facility or before you receive certain Covered Health Care Services and supplies, you must request and obtain approval, known as Authorization. All diabetes related services are provided in accordance with State law. For diabetes related services, please refer to the Diabetes Services section. What is Prior Authorization? Prior Authorization is a clinical evaluation process to determine if the requested Health Care Service is Medically Necessary, a Covered Benefit, and if it is being delivered in the most appropriate health care setting. Our Medical Director or other clinical professional will review the requested Health Care Service and, if it meets our requirements for Coverage and Medical Necessity, it is Authorized (approved) before those services are provided. The Prior Authorization process and requirements are regularly reviewed and updated based on various factors including evidence-based practice guidelines, medical trends, Practitioner/Provider participation, state and federal regulations, and our policies and procedures. A Prior Authorization will specify the length of time for which the Authorization is valid, which in no event shall be for more than twenty-four (24) months. You may revoke an Authorization at any time. A consumer or customer who is the subject of nonpublic personal information may revoke an authorization provided pursuant to this rule at any time, subject to the rights of an individual who acted in reliance on the authorization prior to notice of the revocation. Prior Authorization Is Required Certain services and supplies are Covered Benefits only if we Authorize them prior to the actual service or delivery of supplies. Authorization means our decision that a Health Care Service requested by your Practitioner/Provider or by you has been reviewed and, based upon information available, meets our requirements for Coverage and Medical Necessity, and the requested Health Care Service is therefore approved. If a required Prior Authorization is not obtained for services by Out-of-Network Practitioners/Providers, except for Emergency Care, the Member will be responsible for th...
Prior Authorization. 1) Prior Authorization is a process that helps ensure the appropriate use of Specialty prescription drugs. This program is designed to promote a step wise approach of treatment (use of Drug A before using Drug B), manage the risk of drugs with serious side effects and positively influence the process for managing drug costs.
Prior Authorization. The MHSA Participating Provider must obtain prior authorization from the MHSA for all non- emergency Mental Health and Substance Use Dis- order inpatient admissions including Residential Care, and Other Outpatient Mental Health and Substance Use Disorder Services. For prior authorization of Mental Health and Sub- stance Use Disorder Services, the MHSA Partici- pating Provider should contact the MHSA at 0- 000-000-0000 at least five business days prior to the admission. The MHSA will render a decision on all requests for prior authorization of services as follows:
Prior Authorization. (d) Step Therapy (trial of a lower cost drug before a higher cost drug is covered).
Prior Authorization. Contractor must respond to requests for authorization of services in the format and within the timeframes set forth in the Contract. For each quarter in which the Contractor fails to adjudicate ninety-seven percent (97%) or more of prior authorization requests within the required timeframes, Contractor shall pay liquidated damages in the amount of five thousand, seven hundred fifty dollars ($5,750).
Prior Authorization. ‌ HCWs/PSWs may not be paid for hours that are not prior authorized. Prior authorization for APD is the SDS 4105, or the task list and voucher. Prior authorization for ODDS services is when the individual has an authorized Individual Support Plan (ISP), there is an agreement describing the support to be provided that has been signed by the Consumer and PSW, and there is authorization for services in eXPRS Plan of Care. Prior authorization for OHA services is considered the voucher. In the case of an emergency or urgent situation that occurs after local office hours, the HCW/PSW must notify the case manager or service plan coordinator within two (2) business days.
Prior Authorization. Group and each Group Physician agrees to obtain prior authorization in accordance with any administrative procedures developed in accordance with Section 1.19 or required pursuant to any administrative procedures of third party payors in effect from time to time before rendering any service requiring prior authorization.