Utilization Management Programs. The MCP shall implement clearly defined structures and processes to maximize the effectiveness of the care provided to members pursuant to OAC rule 5160-26-03.1. Pursuant to the criteria in ORC section 5160.34(C), the MCP is prohibited from retroactively denying a prior authorization (PA) request as a utilization management strategy. In addition, the MCP shall permit the retrospective review of a claim submitted for a service where PA was required, but not obtained, pursuant to the criteria in ORC section 5160.34(B)(9). Also ORC section 5160.34 requires the MCPs establish a streamlined provider appeal process relating to adverse PA determinations.
Appears in 4 contracts
Samples: Ohio Medical Assistance Provider Agreement for Managed Care Plan, Ohio Medical Assistance Provider Agreement for Managed Care Plan, Ohio Medical Assistance Provider Agreement for Managed Care Plan
