Prior Authorization Requirement. All transplant procedures must be Prior Authorized for type of transplant and be Medically Necessary and not Experimental or Investigational according to criteria established by Alliant. To Prior Authorize, call (000) 000-0000. The Prior Authorization requirements are a part of the benefit administration of the Contract and are not a treatment recommendation. The actual course of medical treatment the Member chooses remains strictly a matter between the Member and his or her Physician. Your Physician must submit a complete medical history, including current diagnosis and name of the surgeon who will perform the transplant. The surgery must be performed at an Alliant-approved transplant center. The donor, donor recipient, and the transplant surgery must meet required medical selection criteria as defined by Alliant. If the transplant involves a living donor, benefits are as follows: • If a Member receives a transplant and the donor is also covered under this Contract, payment for the Member and the donor will be made under each Member’s Coverage. • If the donor is not covered under this Contract, payment for the Member and the donor will be made under this Contract but will be limited by any payment which might be made under any other hospitalization coverage plan. • If the Member is the donor and the recipient is not covered under this Contract, payment for the Member will be made under this Contract limited by any payment which might be made by the recipient’s hospitalization coverage with another company. No payment will be made under this Contract for the recipient. URGENT CARE SERVICES Covered Services rendered at Urgent Care Centers are paid as outlined in the Summary of Benefits and Coverage. Urgent Care means any medical care or treatment of a medical condition that (A) could seriously jeopardize your life or health or your ability to regain maximum function or (B) in the opinion of the attending Provider, would subject you to severe pain that cannot be adequately managed without care or treatment. Treatment of an Urgent Care medical problem is not life threatening and does not require use of an emergency room at a Hospital; and is not considered an emergency. Please see the Limitations and Exclusions section for Non-Covered Services. OUTPATIENT PRESCRIPTION DRUG PROGRAM (Be aware that large group plans are not required to offer out-patient Prescription Drug benefits; verify coverage with your Human Resources Department if you are a member of a la...
Prior Authorization Requirement. Certain types of care require Prior Authorization by us. This means that you or your Provider must ask us to approve the care before you receive it. A complete and current list of the services subject to Prior Authorization can be found here: xxxx://xxx.xxx.xxx/cs/groups/public/documents/communication/pel_00957159.pdf. The prescription drugs that are subject to a Prior Authorization requirement can be found at xxxx://xxxx.xxx.xxx/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001476. pdf. We may decline payment for unauthorized care. If your Provider is In-network, and you did not agree to receive unauthorized care, your Provider cannot bill you for the care. If you received unauthorized care from a Provider who is not In-network you may be fully responsible for the resulting bills. We do not require Prior Authorization for: · Emergency services · Contraception services that are not subject to any Cost Sharing · Obstetrical or gynecological ultrasound However, we require authorization for continued in-patient care if you are admitted to a Hospital for Emergency treatment, but your condition is stabilized. You or your Provider must notify us as soon as possible from when you begin receiving Emergency in-patient treatment, and within 24 hours after the emergency ends and your condition stabilizes.
Prior Authorization Requirement. Certain types of care require Prior Authorization by us. This means that you or your Provider must ask us to approve the care before you receive it. A complete and current list of the services subject to Prior Authorization can be found here: xxxxx://xxxxxxxxx.xxx.xxx/PEL/DisplayDocument?ContentID=OB_000000002930. The prescription drugs that are subject to a Prior Authorization requirement can be found at xxxx://xxxx.xxx.xxx/idc/groups/public/@phs/@php/documents/phscontent/wcmdev1001476. pdf. We may decline payment for unauthorized care. If your Provider is In-network, and you did not agree to receive unauthorized care, your Provider cannot bill you for the care. If you received unauthorized care from a Provider who is not In-network you may be fully responsible for the resulting bills. We do not require Prior Authorization for: Mental health or substance use disorder services: o Acute or immediately necessary care; o Acute episodes of chronic mental health or substance use disorder conditions; o Initial in-network inpatient or outpatient substance use treatment services. Prescription drugs used for the treatment of substance use disorders, when a generic version is available, the medication is medically necessary and is approved by the Federal Food and Drug Administration; Emergency services Contraception services that are not subject to any Cost Sharing Obstetrical or gynecological ultrasound However, we require authorization for continued in-patient care if you are admitted to a Hospital for Emergency treatment, but your condition is stabilized. You or your Provider must notify us as soon as possible from when you begin receiving Emergency in-patient treatment, and within 24 hours after the Emergency ends and your condition stabilizes.
Prior Authorization Requirement. All transplant procedures must be Pre-Certified for type of transplant and be Medically Necessary and not Experimental or Investigational according to criteria established by Alliant. To Pre-Certify, call the Alliant office using the telephone number on your Identification Card. The Prior Authorization requirements are a part of the benefit administration of the Contract and are not a treatment recommendation. The actual course of medical treatment the Member chooses remains strictly a matter between the Member and his or her Physician. Your Physician must submit a complete medical history, including current diagnosis and name of the surgeon who will perform the transplant. The surgery must be performed at an Alliant-approved Transplant Center. The donor, donor recipient and the transplant surgery must meet required medical selection criteria as defined by Alliant. If the transplant involves a living donor, benefits are as follows: • If a Member receives a transplant and the donor is also covered under this Contract, payment for the Member and the donor will be made under each Member’s Coverage. • If the donor is not covered under this Contract, payment for the Member and the donor will be made under this Contract but will be limited by any payment which might be made under any other hospitalization coverage plan. • If the Member is the donor and the recipient is not covered under this Contract, payment for the Member will be made under this Contract limited by any payment which might be made by the recipient’s hospitalization coverage with another company. No payment will be made under this Contract for the recipient. Please see the “Limitations and Exclusions” section for Non-Covered Services.
