{"component": "clause", "props": {"groups": [{"snippet_links": [{"key": "provider-shall", "type": "clause", "offset": [0, 14]}, {"key": "procedures-and-requirements", "type": "clause", "offset": [45, 72]}, {"key": "provider-manual", "type": "definition", "offset": [90, 105]}, {"key": "section-23", "type": "clause", "offset": [115, 126]}, {"key": "emergency-services", "type": "definition", "offset": [188, 206]}, {"key": "medically-necessary", "type": "definition", "offset": [208, 227]}, {"key": "care-services", "type": "definition", "offset": [248, 261]}, {"key": "pursuant-to-section", "type": "definition", "offset": [280, 299]}, {"key": "california-code-of-regulations", "type": "definition", "offset": [335, 365]}, {"key": "provider-services", "type": "clause", "offset": [416, 433]}, {"key": "in-advance", "type": "clause", "offset": [453, 463]}, {"key": "blue-shield", "type": "definition", "offset": [467, 478]}, {"key": "for-provider", "type": "definition", "offset": [504, 516]}, {"key": "for-payment", "type": "clause", "offset": [532, 543]}, {"key": "basis-of", "type": "clause", "offset": [620, 628]}, {"key": "medical-necessity", "type": "definition", "offset": [629, 646]}, {"key": "for-services", "type": "clause", "offset": [647, 659]}, {"key": "pursuant-to-the", "type": "definition", "offset": [684, 699]}, {"key": "utilization-management-program", "type": "definition", "offset": [724, 754]}, {"key": "provided-that", "type": "definition", "offset": [756, 769]}, {"key": "accurate-information", "type": "definition", "offset": [798, 818]}, {"key": "for-review", "type": "clause", "offset": [834, 844]}, {"key": "prior-to", "type": "clause", "offset": [953, 961]}, {"key": "a-member", "type": "definition", "offset": [993, 1001]}, {"key": "as-required", "type": "clause", "offset": [1003, 1014]}, {"key": "scope-of-the", "type": "clause", "offset": [1064, 1076]}, {"key": "obligation-to-compensate", "type": "clause", "offset": [1150, 1174]}, {"key": "payment-for", "type": "clause", "offset": [1242, 1253]}, {"key": "services-and", "type": "clause", "offset": [1259, 1271]}, {"key": "the-member", "type": "clause", "offset": [1330, 1340]}], "snippet": "Provider shall comply with the Authorization procedures and requirements set forth in the Provider Manual and this Section 2.3. Provider understands and agrees that, except in the case of Emergency Services, Medically Necessary post- stabilization care services deemed Authorized pursuant to Section 1300.71.4(b)(2) of Title 28 of the California Code of Regulations, or as otherwise provided in the Provider Manual, Provider Services must be Authorized in advance by Blue Shield or its delegate in order for Provider to be eligible for payment hereunder. Blue Shield will not retroactively deny Provider\u2019s claims on the basis of Medical Necessity for services reviewed and Authorized pursuant to the Quality Improvement and Utilization Management Program, provided that Provider submitted full and accurate information to Blue Shield for review under its Quality Improvement and Utilization Management Program. If Provider fails to obtain Authorization prior to providing Provider Services to a Member, as required, or if Provider provides services outside of the scope of the Authorization obtained, then Blue Shield, or its delegate, shall have no obligation to compensate Provider for such services; Provider will be deemed to have waived payment for such services and shall not seek payment from Blue Shield, its delegate, or the Member.", "size": 11, "samples": [{"hash": "eUMjamwEnVV", "uri": "/contracts/eUMjamwEnVV#service-authorization", "label": "Independent Provider Agreement", "score": 34.9798545837, "published": true}, {"hash": "lSvrGSEWzPw", "uri": "/contracts/lSvrGSEWzPw#service-authorization", "label": "Allied & Ancillary Provider Agreement", "score": 27.4502544403, "published": true}, {"hash": "1C8YN6UbzIf", "uri": "/contracts/1C8YN6UbzIf#service-authorization", "label": "Allied & Ancillary Provider Agreement", "score": 27.4502544403, "published": true}], "hash": "aec17bbbae1e8e23bc8c1b5d5aa265c5", "id": 2}, {"snippet_links": [{"key": "contractor-will", "type": "clause", "offset": [5, 20]}, {"key": "with-county", "type": "clause", "offset": [33, 44]}, {"key": "authorization-requests", "type": "clause", "offset": [57, 79]}, {"key": "substance-use", "type": "definition", "offset": [150, 163]}, {"key": "contractor-shall", "type": "clause", "offset": [196, 212]}, {"key": "respond-to", "type": "definition", "offset": [213, 223]}, {"key": "for-county", "type": "definition", "offset": [278, 288]}, {"key": "county-shall", "type": "clause", "offset": [344, 356]}, {"key": "notice-of-authorization", "type": "definition", "offset": [389, 412]}, {"key": "care-service", "type": "clause", "offset": [565, 577]}, {"key": "policies-and-procedures", "type": "clause", "offset": [633, 656]}, {"key": "according-to", "type": "definition", "offset": [710, 722]}, {"key": "to-obtain-service", "type": "clause", "offset": [770, 787]}, {"key": "for-non", "type": "clause", "offset": [802, 809]}, {"key": "in-place", "type": "clause", "offset": [1030, 1038]}, {"key": "written-authorization", "type": "definition", "offset": [1059, 1080]}, {"key": "requests-for", "type": "clause", "offset": [1120, 1132]}, {"key": "continuing-authorization", "type": "clause", "offset": [1145, 1169]}, {"key": "residential-treatment-services", "type": "definition", "offset": [1199, 1229]}, {"key": "inpatient-services", "type": "definition", "offset": [1241, 1259]}, {"key": "but-excluding", "type": "clause", "offset": [1261, 1274]}, {"key": "withdrawal-management-services", "type": "definition", "offset": [1275, 1305]}, {"key": "asam-criteria", "type": "clause", "offset": [1345, 1358]}, {"key": "to-ensure", "type": "clause", "offset": [1359, 1368]}, {"key": "the-beneficiary", "type": "definition", "offset": [1374, 1389]}, {"key": "the-service", "type": "clause", "offset": [1417, 1428]}, {"key": "hours-of", "type": "clause", "offset": [1563, 1571]}, {"key": "prior-authorization-request", "type": "definition", "offset": [1576, 1603]}, {"key": "by-the-provider", "type": "clause", "offset": [1620, 1635]}, {"key": "provision-of-a", "type": "clause", "offset": [1743, 1757]}, {"key": "in-a-timely-manner", "type": "definition", "offset": [1790, 1808]}, {"key": "the-client", "type": "clause", "offset": [1825, 1835]}, {"key": "ability-to", "type": "clause", "offset": [2064, 2074]}, {"key": "after-receipt-of", "type": "clause", "offset": [2181, 2197]}, {"key": "request-for-service", "type": "definition", "offset": [2202, 2221]}, {"key": "extension-of", "type": "clause", "offset": [2239, 2251]}, {"key": "calendar-days", "type": "clause", "offset": [2261, 2274]}, {"key": "standard-authorization", "type": "definition", "offset": [2368, 2390]}, {"key": "standard-service-authorizations", "type": "clause", "offset": [2414, 2445]}], "snippet": "19.1 Contractor will collaborate with County to complete authorization requests in line with County and DHCS policy and Contract Exhibit A. [BHRS-77: Substance Use Residential Authorization]\n19.2 Contractor shall respond to County within 24 hours when consultation is necessary for County to make appropriate authorization determinations.\n19.3 County shall provide Contractor with written notice of authorization determinations within the timeframes set forth in BHIN 23-001, or any subsequent DHCS notices.\n19.4 For SUD Non-Residential and Non-Inpatient Levels of Care service authorization:\n19.4.1 Contractor shall follow County\u2019s policies and procedures around non-residential/non- inpatient levels of care according to BHIN 23-001.\n19.4.2 Contractor is not required to obtain service authorization for non-residential/non-inpatient levels of care. Prior authorization is prohibited for non-residential DMC-ODS services.\n19.5 For SUD Residential and Inpatient Levels of Care service authorization:\n19.5.1 Contractor shall have in place, and follow, County written authorization policies and procedures for processing requests for initial and continuing authorization, or prior authorization, for residential treatment services, including inpatient services, but excluding withdrawal management services.\n19.6.2 County will review the DSM and ASAM Criteria to ensure that the beneficiary meets the requirements for the service.\n19.6.3 Prior authorization for residential and inpatient services (excluding withdrawal management services) shall be made within 24 hours of the prior authorization request being submitted by the provider.\n19.6.3.1 County will ensure that prior authorization processes are completed in a manner that assures the provision of a covered SUD service to a client in a timely manner appropriate for the client\u2019s condition.\n19.6.4 Contractor shall alert County when an expediated service authorization decision is necessary due to a client\u2019s specific needs and circumstances that could seriously jeopardize the client\u2019s life or health, or ability to attain, maintain, or regain maximum function. Expediated service authorizations shall not exceed 72 hours after receipt of the request for service, with a possible extension of up to 14 calendar days if the client or provider requests an extension.\n19.6.5 Contractor shall alert County when a standard authorization decision is necessary. Standard service authorizations shall not exceed 14 calendar days following receipt of the request for service, with a possible extension of up to 14 additional calendar days if the client or provider requests an extension.", "size": 10, "samples": [{"hash": "lHQUCINGHHs", "uri": "/contracts/lHQUCINGHHs#service-authorization", "label": "Professional Services", "score": 32.451423645, "published": true}, {"hash": "jsY5d8X4LV", "uri": "/contracts/jsY5d8X4LV#service-authorization", "label": "Professional Services", "score": 32.451423645, "published": true}, {"hash": "hu4luwfDw1C", "uri": "/contracts/hu4luwfDw1C#service-authorization", "label": "Professional Services", "score": 32.451423645, "published": true}], "hash": "cbc4a650dff39fe85e1fba26596950bd", "id": 4}, {"snippet_links": [{"key": "contractor-will", "type": "clause", "offset": [5, 20]}, {"key": "with-county", "type": "clause", "offset": [33, 44]}, {"key": "authorization-requests", "type": "clause", "offset": [57, 79]}], "snippet": "9.1. CONTRACTOR will collaborate with COUNTY to complete authorization requests in line with COUNTY and DHCS policy.", "size": 29, "samples": [{"hash": "7xpmkHORdE8", "uri": "/contracts/7xpmkHORdE8#service-authorization", "label": "Contract for Services", "score": 35.3246459961, "published": true}, {"hash": "lrPCEKRMpcM", "uri": "/contracts/lrPCEKRMpcM#service-authorization", "label": "Contract for Services", "score": 34.9988975525, "published": true}, {"hash": "jc0FRyqHfzq", "uri": "/contracts/jc0FRyqHfzq#service-authorization", "label": "Contract for Services", "score": 34.9195137024, "published": true}], "hash": "738ba58865331fb2825396e37cc211eb", "id": 1}, {"snippet_links": [{"key": "provide-a", "type": "definition", "offset": [16, 25]}, {"key": "authorization-process", "type": "clause", "offset": [34, 55]}, {"key": "county-services", "type": "clause", "offset": [60, 75]}, {"key": "pursuant-to", "type": "definition", "offset": [76, 87]}, {"key": "caloptima-policies", "type": "definition", "offset": [88, 106]}], "snippet": "CalOptima shall provide a written authorization process for County Services pursuant to CalOptima Policies.", "size": 10, "samples": [{"hash": "86ERp57HYcl", "uri": "/contracts/86ERp57HYcl#service-authorization", "label": "Coordination and Provision of Public Health Care Services Contract", "score": 33.5480918884, "published": true}, {"hash": "7L2ZzulLiMH", "uri": "/contracts/7L2ZzulLiMH#service-authorization", "label": "Coordination and Provision of Behavioral Health Care Services Contract", "score": 33.4750137329, "published": true}, {"hash": "6qe9SAyg0Di", "uri": "/contracts/6qe9SAyg0Di#service-authorization", "label": "Coordination and Provision of Public Health Care Services Contract", "score": 32.9376602173, "published": true}], "hash": "264a061082e44a32845d691e0432348f", "id": 3}, {"snippet_links": [{"key": "in-place", "type": "clause", "offset": [123, 131]}, {"key": "written-policies-and-procedures", "type": "clause", "offset": [145, 176]}, {"key": "requests-for", "type": "clause", "offset": [192, 204]}, {"key": "in-effect", "type": "clause", "offset": [304, 313]}, {"key": "to-ensure", "type": "clause", "offset": [314, 323]}, {"key": "application-of", "type": "clause", "offset": [335, 349]}, {"key": "review-criteria", "type": "clause", "offset": [350, 365]}, {"key": "the-requesting", "type": "clause", "offset": [418, 432]}, {"key": "service-authorization-request", "type": "definition", "offset": [527, 556]}, {"key": "health-care-professional", "type": "definition", "offset": [657, 681]}, {"key": "clinical-expertise", "type": "definition", "offset": [702, 720]}, {"key": "the-beneficiary", "type": "definition", "offset": [735, 750]}, {"key": "behavioral-health-needs", "type": "definition", "offset": [753, 776]}, {"key": "notify-the", "type": "clause", "offset": [810, 820]}, {"key": "notice-of-any", "type": "clause", "offset": [875, 888]}, {"key": "contractor-to", "type": "clause", "offset": [905, 918]}, {"key": "the-requirements", "type": "clause", "offset": [1106, 1122]}, {"key": "section-10", "type": "clause", "offset": [1141, 1151]}, {"key": "paragraph-a", "type": "definition", "offset": [1153, 1164]}, {"key": "section-9", "type": "definition", "offset": [1169, 1178]}, {"key": "paragraph-i", "type": "clause", "offset": [1180, 1191]}, {"key": "paragraph-b", "type": "clause", "offset": [1270, 1281]}, {"key": "standard-authorization-decisions", "type": "clause", "offset": [1317, 1349]}, {"key": "provide-notice", "type": "clause", "offset": [1372, 1386]}, {"key": "not-to-exceed", "type": "definition", "offset": [1444, 1457]}, {"key": "calendar-days", "type": "clause", "offset": [1461, 1474]}, {"key": "request-for-service", "type": "definition", "offset": [1500, 1519]}, {"key": "extension-of", "type": "clause", "offset": [1537, 1549]}, {"key": "the-provider", "type": "definition", "offset": [1613, 1625]}, {"key": "the-department", "type": "clause", "offset": [1682, 1696]}, {"key": "upon-request", "type": "clause", "offset": [1697, 1709]}, {"key": "for-additional-information", "type": "clause", "offset": [1718, 1744]}, {"key": "the-standard", "type": "clause", "offset": [1918, 1930]}, {"key": "ability-to", "type": "clause", "offset": [2004, 2014]}, {"key": "health-condition", "type": "clause", "offset": [2180, 2196]}, {"key": "after-receipt-of", "type": "clause", "offset": [2233, 2249]}, {"key": "the-contractor-may", "type": "clause", "offset": [2275, 2293]}, {"key": "time-period", "type": "clause", "offset": [2313, 2324]}, {"key": "if-the-contractor", "type": "clause", "offset": [2396, 2413]}, {"key": "for-treatment", "type": "clause", "offset": [2631, 2644]}, {"key": "one-hour", "type": "definition", "offset": [2674, 2682]}], "snippet": "A. Contractor shall implement mechanisms to assure authorization decision standards are met. The Contractor shall:\n1) Have in place, and follow, written policies and procedures for processing requests for initial and continuing authorizations of services. (42 C.F.R. \u00a7 438.210(b)(1).)\n2) Have mechanisms in effect to ensure consistent application of review criteria for authorization decisions, and shall consult with the requesting provider when appropriate. (42 C.F.R. \u00a7 438.210(b)(2)(i- ii).)\n3) Have any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by a health care professional who has appropriate clinical expertise in addressing the beneficiary\u2019s behavioral health needs. (42 C.F.R. \u00a7 438.210(b)(3).)\n4) Notify the requesting provider, and give the beneficiary written notice of any decision by the Contractor to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. (42 C.F.R. \u00a7 438.210(c)) The beneficiary\u2019s notice shall meet the requirements in Attachment 12, Section 10, paragraph A and Section 9, paragraph I and be provided within the timeframes set forth in Attachment 12, Section 10, paragraph B and Section 9, paragraph I.\nB. For standard authorization decisions, the Contractor shall provide notice as expeditiously as the beneficiary\u2019s condition requires not to exceed 14 calendar days following receipt of the request for service, with a possible extension of up to 14 additional calendar days when:\n1) The beneficiary, or the provider, requests extension; or\n2) The Contractor justifies (to the Department upon request) a need for additional information and how the extension is in the beneficiary\u2019s interest. (42 C.F.R. \u00a7 438.210(d)(1))\nC. For cases in which a provider indicates, or the Contractor determines, that following the standard timeframe could seriously jeopardize the beneficiary\u2019s life or health or ability to attain, maintain, or regain maximum function, the Contractor shall make an expedited authorization decision and provide notice as expeditiously as the beneficiary\u2019s health condition requires and no later than 72 hours after receipt of the request for service. The Contractor may extend the 72-hour time period by up to 14 calendar days if the beneficiary requests an extension, or if the Contractor justifies (to the Department upon request) a need for additional information and how the extension is in the beneficiary\u2019s interest. (42 C.F.R. \u00a7 438.210(d)(2))\nD. The Contractor shall act on an authorization request for treatment for urgent conditions within one hour of the request. (Cal. Code Regs., tit. 9, \u00a7\u00a7 1810.253 1810.405, subd. (c)).", "size": 9, "samples": [{"hash": "bDPUa2jiFUA", "uri": "/contracts/bDPUa2jiFUA#service-authorization", "label": "Standard Agreement", "score": 29.4037189484, "published": true}, {"hash": "hdSK1a4Ytk6", "uri": "/contracts/hdSK1a4Ytk6#service-authorization", "label": "Service Agreement", "score": 26.4091930389, "published": true}, {"hash": "dYEGe0hbX2B", "uri": "/contracts/dYEGe0hbX2B#service-authorization", "label": "Service Agreement", "score": 26.3434963226, "published": true}], "hash": "d3ff12dd6cc202f88fd50dfb1f79a776", "id": 5}, {"snippet_links": [{"key": "the-contractor-may", "type": "clause", "offset": [3, 21]}, {"key": "prior-authorization", "type": "definition", "offset": [34, 53]}, {"key": "respiratory-care-services", "type": "definition", "offset": [93, 118]}, {"key": "the-participant", "type": "clause", "offset": [179, 194]}, {"key": "the-contractor-shall", "type": "clause", "offset": [202, 222]}, {"key": "capitation-services", "type": "definition", "offset": [249, 268]}, {"key": "in-accordance-with", "type": "clause", "offset": [270, 288]}, {"key": "guidelines-for", "type": "clause", "offset": [302, 316]}, {"key": "authorization-decisions", "type": "clause", "offset": [317, 340]}, {"key": "as-specified", "type": "clause", "offset": [351, 363]}, {"key": "the-procedures", "type": "definition", "offset": [385, 399]}, {"key": "the-contractor-must", "type": "clause", "offset": [420, 439]}, {"key": "written-policies-and-procedures", "type": "clause", "offset": [448, 479]}, {"key": "timely-resolution", "type": "clause", "offset": [484, 501]}, {"key": "on-behalf-of", "type": "definition", "offset": [524, 536]}, {"key": "role-of-the", "type": "clause", "offset": [620, 631]}, {"key": "of-the-practice", "type": "clause", "offset": [669, 684]}, {"key": "the-requesting", "type": "clause", "offset": [787, 801]}, {"key": "health-care-professional", "type": "definition", "offset": [982, 1006]}, {"key": "clinical-expertise", "type": "definition", "offset": [1031, 1049]}, {"key": "not-involved", "type": "clause", "offset": [1113, 1125]}, {"key": "a-person", "type": "definition", "offset": [1149, 1157]}, {"key": "development-of-the", "type": "clause", "offset": [1174, 1192]}, {"key": "crisis-intervention-plan", "type": "definition", "offset": [1226, 1250]}, {"key": "behavioral-support-plan", "type": "definition", "offset": [1255, 1278]}, {"key": "if-applicable", "type": "clause", "offset": [1279, 1292]}, {"key": "to-individuals", "type": "clause", "offset": [1343, 1357]}, {"key": "requests-for-services", "type": "clause", "offset": [1369, 1390]}, {"key": "the-individual", "type": "clause", "offset": [1432, 1446]}, {"key": "medically-necessary-services", "type": "definition", "offset": [1478, 1506]}, {"key": "to-a-participant", "type": "clause", "offset": [1507, 1523]}, {"key": "authorized-service", "type": "clause", "offset": [1533, 1551]}, {"key": "basis-of", "type": "clause", "offset": [1776, 1784]}, {"key": "lack-of", "type": "clause", "offset": [1785, 1792]}, {"key": "medical-necessity", "type": "definition", "offset": [1793, 1810]}, {"key": "professional-standards", "type": "definition", "offset": [1886, 1908]}, {"key": "scope-of", "type": "definition", "offset": [1938, 1946]}, {"key": "condition-of", "type": "clause", "offset": [2056, 2068]}, {"key": "nursing-facility", "type": "clause", "offset": [2122, 2138]}, {"key": "for-review", "type": "clause", "offset": [2179, 2189]}, {"key": "prior-to", "type": "clause", "offset": [2190, 2198]}, {"key": "the-review", "type": "clause", "offset": [2263, 2273]}, {"key": "time-frames", "type": "clause", "offset": [2300, 2311]}, {"key": "if-the-contractor", "type": "clause", "offset": [2357, 2374]}, {"key": "residential-habilitation-services", "type": "definition", "offset": [2411, 2444]}, {"key": "services-request-form", "type": "clause", "offset": [2541, 2562]}, {"key": "review-of-the", "type": "clause", "offset": [2776, 2789]}, {"key": "services-within-the", "type": "clause", "offset": [2900, 2919]}, {"key": "team-meeting", "type": "clause", "offset": [3008, 3020]}, {"key": "to-develop", "type": "definition", "offset": [3021, 3031]}, {"key": "supports-coordinator", "type": "clause", "offset": [3040, 3060]}, {"key": "supporting-documentation", "type": "clause", "offset": [3085, 3109]}, {"key": "behavioral-health-practitioner", "type": "definition", "offset": [3117, 3147]}, {"key": "team-members", "type": "clause", "offset": [3494, 3506]}, {"key": "for-the-services", "type": "clause", "offset": [3507, 3523]}, {"key": "in-consultation-with", "type": "definition", "offset": [3659, 3679]}, {"key": "the-medical", "type": "definition", "offset": [3680, 3691]}, {"key": "services-for", "type": "clause", "offset": [3834, 3846]}, {"key": "different-amount", "type": "clause", "offset": [3995, 4011]}, {"key": "services-in-the", "type": "clause", "offset": [4047, 4062]}, {"key": "information-from", "type": "clause", "offset": [4093, 4109]}, {"key": "services-included", "type": "clause", "offset": [4134, 4151]}, {"key": "service-included", "type": "clause", "offset": [4202, 4218]}, {"key": "the-decision", "type": "clause", "offset": [4234, 4246]}, {"key": "in-writing", "type": "clause", "offset": [4315, 4325]}, {"key": "the-notice-must", "type": "clause", "offset": [4452, 4467]}, {"key": "submitted-by", "type": "definition", "offset": [4571, 4583]}, {"key": "notify-the", "type": "clause", "offset": [4617, 4627]}, {"key": "by-the-department", "type": "clause", "offset": [4729, 4746]}, {"key": "in-addition-to-the", "type": "clause", "offset": [4748, 4766]}, {"key": "notification-to", "type": "clause", "offset": [4767, 4782]}, {"key": "service-authorization-request", "type": "definition", "offset": [4843, 4872]}, {"key": "right-of-the", "type": "clause", "offset": [5052, 5064]}, {"key": "upon-request", "type": "clause", "offset": [5092, 5104]}, {"key": "free-of-charge", "type": "clause", "offset": [5109, 5123]}, {"key": "access-to", "type": "definition", "offset": [5136, 5145]}, {"key": "all-documents", "type": "definition", "offset": [5160, 5173]}, {"key": "and-other-information", "type": "clause", "offset": [5184, 5205]}, {"key": "evidentiary-standards", "type": "clause", "offset": [5432, 5453]}, {"key": "coverage-limits", "type": "definition", "offset": [5470, 5485]}, {"key": "file-a-complaint", "type": "clause", "offset": [5525, 5541]}, {"key": "grievance-process", "type": "definition", "offset": [5640, 5657]}, {"key": "fair-hearing", "type": "clause", "offset": [5669, 5681]}, {"key": "information-on", "type": "clause", "offset": [5683, 5697]}, {"key": "right-to-request", "type": "clause", "offset": [5716, 5732]}, {"key": "expedited-review", "type": "definition", "offset": [5733, 5749]}, {"key": "treating-practitioner", "type": "definition", "offset": [5771, 5792]}, {"key": "ability-to", "type": "clause", "offset": [5842, 5852]}, {"key": "provision-of-the-service", "type": "clause", "offset": [5915, 5939]}, {"key": "in-dispute", "type": "definition", "offset": [5940, 5950]}, {"key": "right-to-have", "type": "clause", "offset": [5970, 5983]}, {"key": "benefits-continue", "type": "clause", "offset": [5984, 6001]}, {"key": "resolution-of-the-complaint", "type": "clause", "offset": [6010, 6037]}, {"key": "national-origin", "type": "definition", "offset": [6187, 6202]}, {"key": "must-be-written", "type": "clause", "offset": [6240, 6255]}, {"key": "reading-level", "type": "clause", "offset": [6333, 6346]}, {"key": "whenever-possible", "type": "clause", "offset": [6347, 6364]}, {"key": "to-place", "type": "definition", "offset": [6445, 6453]}, {"key": "limits-on", "type": "clause", "offset": [6466, 6475]}, {"key": "for-the-purpose-of", "type": "definition", "offset": [6486, 6504]}, {"key": "utilization-control", "type": "definition", "offset": [6505, 6524]}, {"key": "provided-that", "type": "definition", "offset": [6526, 6539]}, {"key": "chronic-conditions", "type": "clause", "offset": [6597, 6615]}, {"key": "term-services-and-supports", "type": "clause", "offset": [6633, 6659]}, {"key": "services-are-provided", "type": "clause", "offset": [6788, 6809]}, {"key": "method-of", "type": "clause", "offset": [6888, 6897]}], "snippet": "A. The Contractor may not require prior authorization for Physician, Chiropractor, CRNP, and Respiratory Care services but may require that these services require a referral from the Participant's PCP. The Contractor shall prior authorize all other Capitation Services, in accordance with the practice guidelines for authorization decisions developed as specified in Section 2.1.Y and the procedures in this Section.\nB. The Contractor must develop written policies and procedures for timely resolution of requests submitted on behalf of a Participant to initiate, terminate, reduce, or continue a service, including the role of the PCP and Team, consistent application of the practice guidelines for authorization decisions developed as specified in Section 2.1.Y, and consultation with the requesting Provider when appropriate.\nC. Any decision to deny a request for a service or to authorize a service in an amount, duration, or scope that is less than requested must be made by a health care professional who has the appropriate clinical expertise in treating the Participant's condition or disease and who was not involved and does not supervise a person involved in the development of the Participant's ISP, including the Crisis Intervention Plan and Behavioral Support Plan if applicable.\nD. The Contractor may not structure compensation to individuals who review requests for services in a manner that provides incentives for the individual to deny, limit, or discontinue Medically Necessary services to a Participant.\nE. Each Authorized Service must be the least-restrictive, most- inclusive, and cost-effective feasible option that meets the Participant's needs.\nF. Services may be denied or authorized in an amount, duration, or scope less than requested only on the basis of lack of medical necessity or inconsistency with accepted medical and behavioral health practices and professional standards.\nG. The amount, duration, or scope of a service may not be arbitrarily denied, reduced, or terminated solely because of the diagnosis, illness, or condition of a Participant.\nH. Any request to authorize care in a Nursing Facility or ICF setting must be submitted to BAS for review prior to authorization on the form provided by BAS, and include the ISP. The review by BAS will be within the time frames for authorization specified in this Section. If the Contractor determines that a Participant needs Residential Habilitation Services, the Contractor prior to authorizing the services must submit the ACAP Residential Habilitation Services Request Form to BAS along with any information or documentation needed to support the request to authorize Residential Habilitation Services. The Contractor must also provide BAS with any documents BAS requests as part of its review of the need for Residential Habilitation Services. BAS will review the request to authorize Residential Habilitation Services within the time frames for authorization specified in this Section.\nI. Within five (5) days of the Team meeting to develop ISP the Supports Coordinator must submit the ISP and supporting documentation to the Behavioral Health Practitioner for authorization of the services specified in the ISP. If the Team was unable to reach a consensus on which services to include in an ISP or the amount, duration, or scope of a service include in an ISP, the Supports Coordinator must identify the services on which the Team did and did not reach consensus and explain the positions taken by the Team members for the services on which the Team did not reach consensus.\nJ. After the Behavioral Health Practitioner receives the ISP from the Team, he or she must, in consultation with the Medical and Clinical Directors as appropriate, resolve any areas in the ISP on which the Team did not reach consensus and decide whether to authorize services for the Participant. The Behavioral Health Practitioner may:\n1. Authorize services as specified on the ISP,\n2. Deny one or more services or authorize a different amount, duration, or scope of one or more services in the ISP, or\n3. Request additional information from the Team to support the services included in the ISP or the amount, duration, or scope of a service included in the ISP.\nK. The decision on the ISP must be communicated to the Supports Coordinator and PCP in writing at the same time the Participant or the Participant's representative, as appropriate, is notified of the decision on the ISP. The notice must explain the rationale for the decision and identify any changes between the authorized ISP and the ISP submitted by the Team.\nL. The Contractor must notify the Participant or the Participant's representative as appropriate, in writing using a document approved by the Department, in addition to the notification to the Supports Coordinator and PCP, 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. The notice must include the decision; the specific reasons for the decision including the right of the Participant to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the decision to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested, including medical necessity criteria, and any processes, strategies, or evidentiary standards used in setting coverage limits; instructions on how a Participant can file a Complaint or Grievance if he or she does not agree with the decision and, after exhausting the Complaint or Grievance process, request a Fair Hearing; information on the Participant's right to request expedited review if the Participant's treating practitioner believes that the Participant's life, health, or ability to regain maximum function would be seriously jeopardized absent provision of the service in dispute; the Participant's right to have benefits continue pending resolution of the Complaint or Grievance; and how to request that benefits be continued; and the Participant\u2019s right to be free from discrimination on the basis of race, color, national origin, sex, age, or disability. The notice must be written in language that is readily understandable by a layperson, at a fourth-grade reading level whenever possible and include the taglines listed in Attachment V.\nM. The Contractor is permitted to place appropriate limits on a service for the purpose of utilization control, provided that:\n1. The services supporting Participants with ongoing or chronic conditions who require long-term services and supports are authorized in such a manner that reflects the Participant\u2019s ongoing need for such services and supports.\n2. Family planning services are provided in a manner that protects and enables the Participant\u2019s freedom to choose the method of family planning used.\nN. Time Frames for Service Authorization:", "size": 8, "samples": [{"hash": "eS9Cj7wQR1D", "uri": "/contracts/eS9Cj7wQR1D#service-authorization", "label": "Adult Community Autism Program Agreement", "score": 23.2258720398, "published": true}], "hash": "2b87e37fb1ddc30e3d6586fdfdbd9509", "id": 6}, {"snippet_links": [{"key": "contractor-will", "type": "clause", "offset": [7, 22]}, {"key": "with-county", "type": "clause", "offset": [35, 46]}, {"key": "authorization-requests", "type": "clause", "offset": [59, 81]}, {"key": "contractor-shall", "type": "clause", "offset": [126, 142]}, {"key": "in-place", "type": "clause", "offset": [148, 156]}, {"key": "written-policies-and-procedures", "type": "clause", "offset": [170, 201]}, {"key": "requests-for", "type": "clause", "offset": [217, 229]}, {"key": "by-county", "type": "clause", "offset": [293, 302]}, {"key": "respond-to", "type": "definition", "offset": [337, 347]}, {"key": "in-a-timely-manner", "type": "definition", "offset": [355, 373]}, {"key": "for-county", "type": "definition", "offset": [405, 415]}, {"key": "county-shall", "type": "clause", "offset": [473, 485]}, {"key": "notice-of-authorization", "type": "definition", "offset": [518, 541]}, {"key": "a-member", "type": "definition", "offset": [772, 780]}, {"key": "the-member", "type": "clause", "offset": [848, 858]}, {"key": "ability-to", "type": "clause", "offset": [880, 890]}], "snippet": "3.1.1. CONTRACTOR will collaborate with COUNTY to complete authorization requests in line with COUNTY and DHCS policy.\n3.1.2. CONTRACTOR shall have in place, and follow, written policies and procedures for completing requests for initial and continuing authorizations of services, as required by COUNTY guidance.\n3.1.3. CONTRACTOR shall respond to COUNTY in a timely manner when consultation is necessary for COUNTY to make appropriate authorization determinations.\n3.1.4. COUNTY shall provide CONTRACTOR with written notice of authorization determinations within the timeframes set forth in BHINs 22-016 and 22-017, or any subsequent DHCS notices.\n3.1.5. CONTRACTOR shall alert COUNTY when an expedited authorization decision (no later than 72 hours) is necessary due to a member\u2019s specific needs and circumstances that could seriously jeopardize the member\u2019s life or health, or ability to attain, maintain, or regain maximum function.", "size": 7, "samples": [{"hash": "6oxTLQMnIlu", "uri": "/contracts/6oxTLQMnIlu#service-authorization", "label": "Contract for Services", "score": 36.3130340576, "published": true}, {"hash": "jJ8EylP5JKR", "uri": "/contracts/jJ8EylP5JKR#service-authorization", "label": "Contract for Services", "score": 35.9328918457, "published": true}, {"hash": "4qt7HyA8L1U", "uri": "/contracts/4qt7HyA8L1U#service-authorization", "label": "Contract for Services", "score": 35.4040298462, "published": true}], "hash": "00cf89893a17d2b17a705e1ecbf9d19a", "id": 7}, {"snippet_links": [{"key": "in-accordance-with", "type": "clause", "offset": [92, 110]}, {"key": "information-notices", "type": "clause", "offset": [129, 148]}, {"key": "issued-to", "type": "definition", "offset": [215, 224]}, {"key": "parity-in-mental-health-and-substance-use-disorder-benefits", "type": "clause", "offset": [233, 292]}, {"key": "effective-date-of-this-contract", "type": "definition", "offset": [311, 342]}, {"key": "state-and-federal-regulations", "type": "clause", "offset": [363, 392]}, {"key": "the-contractor-shall", "type": "clause", "offset": [420, 440]}, {"key": "in-place", "type": "clause", "offset": [450, 458]}, {"key": "written-policies-and-procedures", "type": "clause", "offset": [472, 503]}, {"key": "requests-for", "type": "clause", "offset": [519, 531]}, {"key": "in-effect", "type": "clause", "offset": [631, 640]}, {"key": "to-ensure", "type": "clause", "offset": [641, 650]}, {"key": "application-of", "type": "clause", "offset": [662, 676]}, {"key": "review-criteria", "type": "clause", "offset": [677, 692]}, {"key": "authorization-decisions", "type": "clause", "offset": [697, 720]}, {"key": "the-requesting", "type": "clause", "offset": [745, 759]}, {"key": "service-authorization-request", "type": "definition", "offset": [854, 883]}, {"key": "health-care-professional", "type": "definition", "offset": [984, 1008]}, {"key": "clinical-expertise", "type": "definition", "offset": [1029, 1047]}, {"key": "the-beneficiary", "type": "definition", "offset": [1062, 1077]}, {"key": "behavioral-health-needs", "type": "definition", "offset": [1080, 1103]}, {"key": "notify-the", "type": "clause", "offset": [1137, 1147]}, {"key": "notice-of-any", "type": "clause", "offset": [1201, 1214]}, {"key": "contractor-to", "type": "clause", "offset": [1231, 1244]}, {"key": "the-requirements", "type": "clause", "offset": [1432, 1448]}, {"key": "section-10", "type": "clause", "offset": [1467, 1477]}, {"key": "paragraph-a", "type": "definition", "offset": [1479, 1490]}, {"key": "section-9", "type": "definition", "offset": [1495, 1504]}, {"key": "paragraph-i", "type": "clause", "offset": [1506, 1517]}, {"key": "paragraph-b", "type": "clause", "offset": [1596, 1607]}, {"key": "with-authorization", "type": "clause", "offset": [1667, 1685]}, {"key": "the-standard", "type": "clause", "offset": [2081, 2093]}, {"key": "ability-to", "type": "clause", "offset": [2167, 2177]}, {"key": "provide-notice", "type": "clause", "offset": [2290, 2304]}, {"key": "health-condition", "type": "clause", "offset": [2343, 2359]}, {"key": "after-receipt-of", "type": "clause", "offset": [2396, 2412]}, {"key": "request-for-service", "type": "definition", "offset": [2417, 2436]}, {"key": "the-contractor-may", "type": "clause", "offset": [2438, 2456]}, {"key": "time-period", "type": "clause", "offset": [2476, 2487]}, {"key": "calendar-days", "type": "clause", "offset": [2500, 2513]}, {"key": "if-the-contractor", "type": "clause", "offset": [2559, 2576]}, {"key": "the-department", "type": "clause", "offset": [2591, 2605]}, {"key": "upon-request", "type": "clause", "offset": [2606, 2618]}, {"key": "for-additional-information", "type": "clause", "offset": [2643, 2669]}, {"key": "for-treatment", "type": "clause", "offset": [2810, 2823]}, {"key": "one-hour", "type": "definition", "offset": [2853, 2861]}], "snippet": "A. Contractor shall implement mechanisms to assure authorization decision standards are met in accordance with Behavioral Health Information Notices (BHINs) 22-016 and 22-017, or any subsequent Departmental notices issued to address parity in mental health and substance use disorder benefits subsequent to the effective date of this contract, and any applicable state and federal regulations. (42 C.F.R. \u00a7 438.910(d).) The Contractor shall:\n1) Have in place, and follow, written policies and procedures for processing requests for initial and continuing authorizations of services. (42 C.F.R. \u00a7 438.210(b)(1).)\n2) Have mechanisms in effect to ensure consistent application of review criteria for authorization decisions, and shall consult with the requesting provider when appropriate. (42 C.F.R. \u00a7 438.210(b)(2)(i- ii).)\n3) Have any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested be made by a health care professional who has appropriate clinical expertise in addressing the beneficiary\u2019s behavioral health needs. (42 C.F.R. \u00a7 438.210(b)(3).)\n4) Notify the requesting provider and give the beneficiary written notice of any decision by the Contractor to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. (42 C.F.R. \u00a7 438.210(c)) The beneficiary\u2019s notice shall meet the requirements in Attachment 12, Section 10, paragraph A and Section 9, paragraph I and be provided within the timeframes set forth in Attachment 12, Section 10, paragraph B and Section 9, paragraph G.\nB. The Contractor shall comply with authorization timeframes in accordance with BHINs 22-016 and 22-017, or any subsequent Departmental notices issued to address parity in mental health and substance use disorder benefits subsequent to the effective date of this contract, as well as any applicable state and federal regulations. (42 C.F.R. \u00a7 438.910(d).)\nC. For cases in which a provider indicates, or the Contractor determines, that following the standard timeframe could seriously jeopardize the beneficiary\u2019s life or health or ability to attain, maintain, or regain maximum function, the Contractor shall make an expedited authorization decision and provide notice as expeditiously as the beneficiary\u2019s health condition requires and no later than 72 hours after receipt of the request for service. The Contractor may extend the 72-hour time period by up to 14 calendar days if the beneficiary requests an extension, or if the Contractor justifies (to the Department upon request), and documents, a need for additional information and how the extension is in the beneficiary\u2019s interest. (42 C.F.R. \u00a7 438.210(d)(2))\nD. The Contractor shall act on an authorization request for treatment for urgent conditions within one hour of the request. (Cal. Code Regs., tit. 9, \u00a7\u00a7 1810.253 1810.405, subd. (c)).", "size": 7, "samples": [{"hash": "b0xuuLgxKv5", "uri": "/contracts/b0xuuLgxKv5#service-authorization", "label": "Service Agreement", "score": 34.2808456421, "published": true}, {"hash": "cQybtrdPzMV", "uri": "/contracts/cQybtrdPzMV#service-authorization", "label": "Service Agreement", "score": 33.8602142334, "published": true}, {"hash": "at7CxyDMftP", "uri": "/contracts/at7CxyDMftP#service-authorization", "label": "Standard Agreement", "score": 32.6392860413, "published": true}], "hash": "fa5b20555b3c0afce98fc3a5da8ef638", "id": 8}, {"snippet_links": [{"key": "all-services", "type": "clause", "offset": [51, 63]}, {"key": "community-care", "type": "clause", "offset": [172, 186]}, {"key": "consistent-with", "type": "definition", "offset": [216, 231]}, {"key": "the-individual", "type": "clause", "offset": [259, 273]}, {"key": "services-and", "type": "clause", "offset": [319, 331]}, {"key": "dd-services", "type": "definition", "offset": [353, 364]}, {"key": "in-accordance-with", "type": "clause", "offset": [462, 480]}, {"key": "policies-and-procedures", "type": "clause", "offset": [495, 518]}, {"key": "the-service", "type": "clause", "offset": [583, 594]}, {"key": "services-included", "type": "clause", "offset": [608, 625]}, {"key": "expenditure-guidelines", "type": "clause", "offset": [633, 655]}, {"key": "the-rates", "type": "clause", "offset": [678, 687]}, {"key": "subject-to-change", "type": "clause", "offset": [738, 755]}, {"key": "upon-notice", "type": "definition", "offset": [756, 767]}], "snippet": "CDDP must authorize Services as outlined below:\na. All Services, regardless of service setting or unless otherwise noted, must be authorized in eXPRS or MMIS for Long-Term Community Care Nursing (LTCCN), in a manner consistent with rule, by the CDDP in which the Individual is enrolled and is receiving Case Management Services and found eligible for I/DD Services as outlined in OAR Chapter 411, Division 320. This authorization must be obtained and documented in accordance with OARs and ODHS policies and procedures.\nb. All Services must be authorized at the appropriate rate for the service setting. All Services included in the expenditure guidelines must be entered using the rates detailed in the expenditure guidelines. Rates are subject to change upon notice from ODHS.", "size": 5, "samples": [{"hash": "ja6IQB3ZJpk", "uri": "/contracts/ja6IQB3ZJpk#service-authorization", "label": "Intergovernmental Grant Agreement", "score": 34.4822540283, "published": true}, {"hash": "8Zi20O4cgoP", "uri": "/contracts/8Zi20O4cgoP#service-authorization", "label": "Intergovernmental Grant Agreement", "score": 34.1346588135, "published": true}, {"hash": "kjC70o09oRR", "uri": "/contracts/kjC70o09oRR#service-authorization", "label": "Intergovernmental Grant Agreement", "score": 32.5078926086, "published": true}], "hash": "b6943a40ffcf1271f8435decfba9aa6a", "id": 9}, {"snippet_links": [{"key": "the-contractor-may", "type": "clause", "offset": [0, 18]}, {"key": "limits-on", "type": "clause", "offset": [25, 34]}, {"key": "in-accordance-with", "type": "clause", "offset": [45, 63]}, {"key": "regulations-and-requirements", "type": "clause", "offset": [72, 100]}, {"key": "this-contract", "type": "definition", "offset": [104, 117]}], "snippet": "The Contractor may place limits on a service in accordance with federal regulations and requirements of this Contract as set forth in this section and Section 30.1 \u201c", "size": 4, "samples": [{"hash": "Xg5VoqwVmn", "uri": "/contracts/Xg5VoqwVmn#service-authorization", "label": "Medicaid Managed Care Contract", "score": 24.0102672577, "published": true}, {"hash": "9rTieAaTNsM", "uri": "/contracts/9rTieAaTNsM#service-authorization", "label": "Medicaid Managed Care Contract", "score": 24.0102672577, "published": true}, {"hash": "gbXLVajEJuV", "uri": "/contracts/gbXLVajEJuV#service-authorization", "label": "Medicaid Managed Care Contract", "score": 23.7241611481, "published": true}], "hash": "ff8555ddd228abced2e43ca436ca9fe3", "id": 10}], "next_curs": "Cl4SWGoVc35sYXdpbnNpZGVyY29udHJhY3RzcjoLEhZDbGF1c2VTbmlwcGV0R3JvdXBfdjU2Ih5zZXJ2aWNlLWF1dGhvcml6YXRpb24jMDAwMDAwMGEMogECZW4YACAA", "clause": {"title": "Service Authorization", "children": [["", ""], ["authorization-limits", "Authorization Limits"], ["information-required-for-a-decision", "Information Required for a Decision"], ["communication-of-guidelines", "Communication of Guidelines"], ["resolving-disputes", "Resolving Disputes"]], "parents": [["signatures", "SIGNATURES"], ["software-security", "SOFTWARE SECURITY"], ["notification-of-data-security-incident", "Notification of Data Security Incident"], ["provider-services", "Provider Services"], ["functions-and-duties-of-caloptima", "Functions and Duties of Caloptima"]], "size": 152, "id": "service-authorization", "related": [["overtime-authorization", "Overtime Authorization", "Overtime Authorization"], ["authorization-etc", "Authorization, Etc", "Authorization, Etc"], ["power-authorization", "Power; Authorization", "Power; Authorization"], ["required-authorizations", "Required Authorizations", "Required Authorizations"], ["legal-authorization", "LEGAL AUTHORIZATION", "LEGAL AUTHORIZATION"]], "related_snippets": [], "updated": "2025-07-24T06:49:03+00:00", "also_ask": ["What minimum elements must a Service Authorization clause include to ensure enforceability?", "How can the clause be drafted to limit unauthorized or implied service expansions?", "What negotiation leverage does this clause provide in scope or fee disputes?", "How do courts interpret ambiguous Service Authorization language in contract disputes?", "How does this clause compare to industry standards or statutory requirements for service agreements?"], "drafting_tip": "Specify authorized services, identify responsible parties, and set approval procedures to prevent unauthorized actions and clarify accountability.", "explanation": "The Service Authorization clause defines the conditions under which one party is permitted to access or use specific services provided by the other party. Typically, it outlines the scope of authorized activities, any limitations or restrictions, and the process for obtaining or revoking authorization. For example, it may specify which employees can use a software platform or under what circumstances additional permissions are required. This clause ensures that service usage is controlled and compliant with agreed terms, thereby preventing unauthorized access and potential misuse."}, "json": true, "cursor": ""}}