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. 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 xxx.xxx.xxx. 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. Prior authorization allows the Member and provider to verify with Blue Shield or Blue Shield’s MHSA that (1) the proposed services are a Benefit of the Member’s plan, (2) the proposed services are Medically Necessary, and (3) the proposed setting is clinically appropriate. The prior authorization process also informs the Member and provider when Benefits are limited to services rendered by Participating Providers or MHSA Participating Providers (See the Summary of Benefits). A decision will be made on all requests for prior authorization within five business days from receipt of the request. The treating provider will be notified of the decision within 24 hours and written notice will be sent to the Member and provider within two business days of the decision. For urgent services when the routine decision making process might seriously jeopardize the life or health of a Member or when the Member is experiencing severe pain, a decision will be rendered as soon as possible to accommodate the Member’s condition, not to exceed 72 hours from receipt of the request. (See the Outpatient Prescription Drug Benefits section for specific information about prior authorization for outpatient prescription drugs). If prior authorization was not obtained, and services provided to the Member are determined not to be a Benefit of the plan or were not medically necessary, coverage will be denied. Prior Authorization for Radiological and Nuclear Imaging Procedures Prior authorization is required for radiological and nuclear imaging procedures. The Member or provider should call 0-000-000-0000 for prior authorization of the following radiological and nuclear imaging procedures when performed within California on an outpatient, non-emergency basis:
Prior Authorization. This means a determination by our medical directors, or their designees, that an admission, extension of stay, or other health care service has been reviewed and that, based on the information provided, it satisfies our utilization review requirements. We will then pay for the covered benefit, provided the general exclusion provisions, and any deductible, copayment, coinsurance, or other policy requirements have been met. Reconstructive Surgery. This is limited to reconstructive surgery, incidental to or following surgery, resulting from injury or illness of the involved part, or to correct a congenital disease or anomaly resulting in functional defect in a dependent child, as determined by the attending physician.
Prior Authorization. (d) Step Therapy (trial of a lower cost drug before a higher cost drug is covered).
Prior Authorization. Certain prescription drugs may require prior authorization before you can have your prescription filled at the pharmacy. For information, you may call PIC at the phone number listed on the inside front cover of this contract. These prescription drugs may include, but are not limited to:
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. 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: