Refer to. 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. This does not apply to Benefits mandated by law. 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 may be responsible for the resulting charges. Services provided beyond the scope of the Prior Authorization may not be Covered. Prior Authorization when In-network When you seek specific Covered Services from In-network Practitioners/Providers, our In- network Practitioner/Provider is responsible for obtaining Prior Authorization from us before providing the Covered Services, except for Emergency Care. You will not be liable for charges resulting from the In-network Practitioner’s/Provider’s failure to obtain the required Prior Authorization. Prior Authorization when Out-of-network Covered services obtained from an Out-of-network Practitioner/Provider or outside New Mexico will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. If required medical services are not available from In-network Practitioners/Providers, the Primary Care Physician must request Prior Authorization and obtain written Authorization from our Medical Director before you may receive Out-of-network services. Services of an Out-of-network Practitioner/Provider may not be Covered unless this Authorization is obtained prior to receiving the services. You may be responsible for charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network Practitioner/Provider. In determining whether a referral to an Out-of-network Practitioner/Provider is necessary, we, in consultation with your referring In-network Physician and/or PCP will consider the following circumstances: ➢ Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation. ➢ Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment. ➢ Geography – The In-network Practitioner/Provider is not located within a reasonable distance from the patient’s residence. A “reasonable distance” is defined as travel that would not place you at any medical risk. ➢ Continuity – If the requested Out-of-network Practitioner/Provider has a well- established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of thirty (30) days as needed to ensure continuity of care. ➢ Any Prior Authorization requested s i m p l y for your convenience will not be considered to be reasonable.
Appears in 1 contract
Samples: Presbyterian Health Plan
Refer to. Before Generally you are admitted as an Inpatient will not have claims to file or papers to fill out in order for 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 claim 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 providedbe paid. 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. This does not apply to Benefits mandated by law. 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 may be responsible xxxx us directly for the resulting chargescost of services. Services provided beyond Most services require Cost Sharing (Deductible, Coinsurance and/or Copayments) at the scope time of the Prior Authorization may not service. The amount of Cost Sharing for each service can be Coveredfound in your Summary of Benefits and Coverage. Prior Authorization when In-network When Practitioners and Providers cannot xxxx you seek specific Covered Services from for any additional costs over and above your Cost Sharing amounts. We do not require our In-network Practitioners/ProvidersProviders to comply with any specified numbers, our In- network Practitioner/Provider is responsible for obtaining Prior Authorization from us before providing the Covered Servicestargeted averages, except for Emergency Careor maximum duration of patient visits. You will not be liable for charges resulting from the In-network Practitioner’s/Provider’s failure to obtain the required Prior Authorization. Prior Authorization when Out-of-network Practitioners/Providers Out-of-network Practitioners/Providers are health care Practitioners/Providers, including non-medical facilities, who have not entered into an agreement with us to provide Health Care Services to PHP Members. Covered services Health Care Services obtained from an Out-of-network Practitioner/Provider or outside New Mexico the Service Area will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. If required medical services are You will not available from In-network Practitioners/Providers, the Primary Care Physician must request Prior Authorization and obtain written Authorization from our Medical Director before you may receive pay higher or additional Cost Sharing amounts under such circumstances. Refer to Services provided by an Out-of-network Practitioner/Provider, except Emergency services, require that your Primary Care Physician request and obtain written approval (Authorization) from our Medical Director BEFORE services are rendered. Services Otherwise, you will be responsible for payment. Please refer to the Prior Authorization Section for more information on Prior Authorization requirements. If the services of an Out-of-network Practitioner/Provider may are required, your In-network Practitioner/Provider must request and obtain Prior Authorization from our Medical Director BEFORE services are performed, otherwise, we will not be Covered unless this Authorization is obtained prior to receiving Cover the services. You may services and you will be responsible for charges resulting payment. Before the Medical Director may deny a request for specialist services that are unavailable from failure to obtain Prior Authorization for services provided by the Outan In-of- network Network Practitioner/Provider, the request must be reviewed by a specialist similar to the type of specialist to whom the Prior Authorization is requested. In determining whether a referral Prior Authorization to an Out-of-network Practitioner/Provider is necessaryreasonable, we, in consultation with your referring In-network Physician and/or PCP we will consider the following circumstances: ➢ Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation. ➢ Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment. ➢ Geography – The In-network Practitioner/Provider is not located within a reasonable distance from the patient’s your residence. A “reasonable distance” is defined as travel that would not place you at any medical risk. ➢ Continuity – If the requested Out-of-network Practitioner/Provider has a well- well-established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of thirty (30) 30 days as needed to ensure continuity of care. ➢ Any Prior Authorization requested s i m p l y for your convenience will not be considered to be reasonable.
Appears in 1 contract
Samples: Presbyterian Health Plan
Refer to. 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 procedures. 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 eve t 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 pro ided 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. This does not apply to Benefits mandated by law. 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 may be responsible for the resulting charges. Services provided beyond the scope of the Prior Authorization may not be Covered. Prior Authorization when In-network When you seek specific Covered Services from In-network Practitioners/Providers, our In- network Practitioner/Provider is responsible for obtaining Prior Authorization from us before providing the Covered Services, except for Emergency Care. You will not be liable for charges resulting from the In-network Practitioner’s/Provider’s failure to obtain the required Prior Authorization. Prior Authorization when Out-of-network Covered services obtained from an Out-of-network Practitioner/Provider or outside New Mexico will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. Important Information If required medical services are not available from In-network Practitioners/Providers, the Primary Care Physician must request Prior Authorization and obtain written Authorization from our Medical Director before you may receive Out-of-network services. Services of an Out-of-network Practitioner/Provider may not be Covered unless this Authorization is obtained prior to receiving the services. You may be responsible for charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network Practitioner/Provider. In determining whether a referral to an Out-of-network Practitioner/Provider is necessary, we, in consultation with your referring In-network Physician and/or PCP will consider the following circumstances: ➢ Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation. ➢ Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment. ➢ Geography – The In-network Practitioner/Provider is not located within a reasonable distance from the patient’s residence. A “reasonable distance” is defined as travel that would not place you at any medical risk. ➢ Continuity – If the requested Out-of-network Practitioner/Provider has a well- established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of thirty (30) days as needed to ensure continuity of care. ➢ Any Prior Authorization requested s i m p l y for your convenience will not be considered to be reasonable. Services That Require Prior Authorization In or Out-of Network Prior Authorization is required for Inpatient admissions, and all services related to the inpatient admission before you receive these services In-network or Out-of-network from any Practitioner/Provider, Health Care Facility or other Health Care Professional. Our network of Practitioners/Providers will obtain Prior Authorization for you when you receive care In- CSC Call P 505‐923‐5678 network. You are responsible for obtaining Prior Authorization before you receive care Out- of-network, except for Emergency Care. f you want to know more about Prior Authorization, please call our Presbyterian Customer ervice Center, as soon as possible before services are provided, Monday through Friday from 1‐800‐356‐2219 :00 a.m. to 6:00 p.m. at (000) 000-0000 or toll-free at 0-000-000-0000. Hearing impaired users may call the TTY line at 711 or toll-free 0-000-000-0000. You may also visit our website at xxx.xxx.xxx.
Appears in 1 contract
Samples: Presbyterian Health Plan
Refer to. 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. This does not apply to Benefits mandated by law. 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 may be responsible for the resulting charges. Services provided beyond the scope of the Prior Authorization may not be Covered. Prior Authorization when In-network When you seek specific Covered Services from In-network Practitioners/Providers, our In- network Practitioner/Provider is responsible for obtaining Prior Authorization from us before providing the Covered Services, except for Emergency Care. You will not be liable for charges resulting from the In-network Practitioner’s/Provider’s failure to obtain the required Prior Authorization. Prior Authorization when Out-of-network Covered services obtained from an Out-of-network Practitioner/Provider or outside New Mexico will not be Covered unless such services are not reasonably available from an In-network Practitioner/Provider or in cases of an emergency. If required medical services are not available from In-network Practitioners/Providers, the Primary Care Physician must request Prior Authorization and obtain written Authorization from our Medical Director before you may receive Out-of-network services. Services of an Out-of-network Practitioner/Provider may not be Covered unless this Authorization is obtained prior to receiving the services. You may be responsible for charges resulting from failure to obtain Prior Authorization for services provided by the Out-of- network Practitioner/Provider. In determining whether a referral to an Out-of-network Practitioner/Provider is necessary, we, in consultation with your referring In-network Physician and/or PCP will consider the following circumstances: ➢ Availability – The In-network Practitioner/Provider is not reasonably available to see you in a timely fashion as dictated by the clinical situation. ➢ Competency – The In-network Practitioner/Provider does not have the necessary training or expertise required to render the service or treatment. ➢ Geography – The In-network Practitioner/Provider is not located within a reasonable distance from the patient’s residence. A “reasonable distance” is defined as travel that would not place you at any medical risk. ➢ Continuity – If the requested Out-of-network Practitioner/Provider has a well- established professional relationship with you and is providing ongoing treatment of a specific medical problem, you will be allowed to continue seeing that specialist for a minimum of thirty (30) days as needed to ensure continuity of care. ➢ Any Prior Authorization requested s i m p l y for your convenience will not be considered to be reasonable.
Appears in 1 contract
Samples: Presbyterian Health Plan
