Common use of Authorization of Services Clause in Contracts

Authorization of Services. The Contractor will not provide authorization for inpatient hospital services. Providers will continue to seek authorization from the agency’s QIO Contractor. The Contractor must define service authorization in a manner that at least includes an Enrollee’s request for the provision of a service. The Contractor must have in place written policies and procedures for the processing of requests for initial and continuing authorizations of services. The Contractor must have a mechanism to ensure consistent application of review criteria for authorization decisions that includes consultation with the requesting provider when appropriate. Any decision to deny a service authorization request 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 appropriate clinical expertise in treating the Enrollee’s condition or disease. The Contractor must notify the requesting provider and the Enrollee in writing of any decision by the Contractor to deny an authorization request or to authorize a service in an amount, duration, or scope that is less than requested. The notice must meet the requirements specified in 42 CFR § 438.404. For standard authorization decisions, the Contractor must provide notice within fourteen (14) calendar days following receipt of the request for services with a possible extension of up to fourteen (14) additional calendar days if the Enrollee or the provider requests an extension or the Contractor justifies to the Division a need for additional information and how the extension is in the Enrollee’s best interest. Expedited authorization decisions are those in which a provider indicates or the Contractor determines that following the standard authorization decision timeframe could seriously jeopardize the Enrollee’s life or health or ability to attain, maintain, or regain maximum function. The Contractor must provide decision notice no later than three (3) working days after receipt of the request for service for an expedited authorization request with a possible extension of up to fourteen (14) additional calendar days if the Enrollee or the provider requests an extension or the Contractor justifies to the Division a need for additional information and how the extension is in the Enrollee’s best interest. Compensation to individuals or utilization management entities must not be structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any Enrollee.

Authorization of Services. The Contractor will not provide authorization for inpatient hospital services. Providers will continue to seek authorization from the agency’s QIO Contractor. The Contractor must define service authorization in a manner that at least includes an Enrollee’s request for the provision of a service. The Contractor must have in place written policies and procedures for For the processing of requests for initial and continuing authorizations authorization of services, the CONTRACTOR shall: Ensure that prior authorization is not required for codes specified by HCA; Define service authorization requests in a manner that includes a Member’s request for the provision of services; Have, and follow, written policies and procedures for processing requests for initial and continuing authorizations for services, and require that its Major Subcontractors or Subcontractors do the same; Have, and follow, written policies and procedures to issue extended prior authorization for Covered Services provided to address chronic conditions that require care on an ongoing basis. The Contractor must have These services shall be authorized for an extended period of time, and the CONTRACTOR shall provide for a mechanism review and periodic update of the course of treatment, according to best practices; Have in effect mechanisms to ensure consistent application of review UM criteria for authorization decisions that includes consultation decisions; Consult with the requesting provider Provider when appropriate. Any ; Require that any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested must requested, be made by a health care professional who has appropriate clinical expertise in treating the EnrolleeMember’s condition or disease, such as the CONTRACTOR’s medical director. The Contractor CONTRACTOR shall contract with a Board Certified Behavioral Analyst (BCBA) for utilization review of Applied Behavior Analysis prior authorization requests. The CONTRACTOR must notify ensure the BCBA contracted has no conflict of interests with individuals and/or entities requesting provider and prior authorization for a Member; Comply with the Enrollee in writing most rigorous standards or applicable provisions of any decision by either the Contractor to deny an authorization request or to authorize a service in an amountNew Mexico Health Insurance Prior Authorization Act, durationNCQA, HCA regulation, or scope 42 C.F.R. part 438.210(d) related to timeliness of decisions, including routine/non-urgent and emergent situations; The CONTRACTOR shall ensure that is less than requestedrequired time frames for decisions are not affected by a “pend” decision. The notice decision-making time frames must meet accommodate the requirements specified clinical urgency of the situation and must not result in 42 CFR § 438.404the delay of the provision of Covered Services to Members. For The CONTRACTOR shall adjudicate standard prior authorization decisions, the Contractor must provide notice requests within fourteen seven (147) calendar days following Business Days after receipt of all necessary and relevant documentation supporting a prior authorization request. Prior authorizations shall be deemed granted for determinations not made within the request for services with a possible seven (7) Business Day turn-around time, except where: An extension of up to fourteen (14) additional calendar days if Calendar Days is granted based upon the Enrollee Member’s or provider’s request for an extension; or The CONTRACTOR justifies (to HCA upon written request) the provider requests an extension or the Contractor justifies to the Division a need for additional information and how the extension is in the EnrolleeMember’s best interest. Expedited authorization decisions are those ; If the CONTRACTOR extends the time frame, the CONTRACTOR must give the Member written notice of the reason for the decision to extend the time frame and inform the Member of the right to file a Grievance in accordance with Section 4.17 of this Agreement if the Member disagrees with the decision; and In cases in which a provider indicates the Provider indicates, or the Contractor determines CONTRACTOR determines, that following the standard authorization decision timeframe time frame could seriously jeopardize the EnrolleeMember’s life or health or the ability to attain, maintain, or regain maximum maximal function. The Contractor , the CONTRACTOR must provide make an expedited authorization decision notice no later than three twenty-four (324) working days hours after the receipt of all necessary and relevant documentation supporting the request prior authorization request. Prior authorizations shall be deemed granted for service for an determinations not made within the twenty-four (24) hour turn-around time. In the event that the expedited authorization request decision is to deny or limit services, the CONTRACTOR shall automatically file an Appeal on behalf of the Member in accordance with a possible extension Section 4.17.4 of up this Agreement. Establish policies and procedures that describe how UM decisions will be communicated to fourteen (14) additional calendar days if the Enrollee Member and the Member’s PCP or to the provider requests requesting the authorization; Provide UM decision criteria to Providers, Members and their families, and the public upon request; and Develop and offer Providers an extension or opportunity to request peer-to-peer reviews of the Contractor justifies to the Division CONTRACTOR’s UM decisions. The CONTRACTOR must offer a need for additional information and how the extension is in the Enrolleepeer-to-peer review within 24 hours of a Provider’s best interest. Compensation to individuals or utilization management entities must not be structured so as to provide incentives for the individual or entity to deny, limitrequest, or discontinue medically necessary services at the Provider’s first availability, for a peer-to-peer review at a mutually-agreed upon time. The CONTRACTOR must ensure that staff conducting peer-to-peer reviews are the CONTRACTOR’s Medical Directors or health care professionals who have clinical expertise in treating the Member's condition. The CONTRACTOR staff conducting the peer-to-peer review must clearly identify the documentation the Provider must proffer to any Enrolleeobtain approval of the specific item, procedure, or service; or identify a more appropriate clinical course of action based upon accepted clinical guidelines.

Authorization of Services. The Contractor will not shall provide authorization education and ongoing guidance and training to Individuals and providers about its UM protocols and Level of Care Guidelines, including ASAM Criteria for inpatient hospital services. Providers will continue to seek authorization from the agency’s QIO ContractorSUD services for admission, continued stay, and discharge criteria. The Contractor must define service authorization in a manner that at least includes an Enrollee’s request for the provision of a service. The Contractor must shall have in place written policies and procedures for the processing of requests for initial and continuing authorizations of services. The Contractor must have a mechanism effect mechanisms to ensure consistent application of UMP review criteria for authorization decisions that includes consultation decisions. The Contractor shall consult with the requesting provider when appropriate. Any decision Timeframes for Authorization Decisions The Contractor is required to deny acknowledge receipt of a service standard authorization request for behavioral health inpatient services within two (2) hours and provide a decision within twelve (12) hours of receipt of the request. The Contractor shall provide for the following timeframes for authorization decisions and notices: For denial of payment that may result in payment liability for the Individual, at the time of any Action or to authorize a service in an amountAdverse Authorization Determination affecting the claim. For termination, durationsuspension, or scope that is less than requested must reduction of previously authorized Contracted Services, ten (10) calendar days prior to such termination, suspension, or reduction, unless the criteria stated in 42 C.F.R. §§ 431.213 and 431.214 are met. Standard authorizations for planned or elective service determinations: The authorization decisions are to be made by a health care professional who has appropriate clinical expertise in treating and notices of Adverse Authorization Determinations are to be provided as expeditiously as the EnrolleeIndividual’s condition or diseaserequires. The Contractor must notify the requesting provider and the Enrollee in writing of any make a decision by the Contractor to deny an authorization request or to authorize a service in an amountapprove, durationdeny, or scope that request additional information from the provider within five (5) calendar days of the original receipt of the request. If additional information is less than required and requested. The notice must meet the requirements specified in 42 CFR § 438.404. For standard authorization decisions, the Contractor must provide notice within fourteen give the provider five (145) calendar days following to submit the information and then approve or deny the request within four (4) calendar days of the receipt of the request for services with a possible additional information. An extension of up to fourteen (14) additional calendar days if (not to exceed twenty-eight (28) calendar days total) is allowed under the Enrollee following circumstances: The Individual or the provider requests an extension the extension; or the The Contractor justifies to the Division and documents a need for additional information and how the extension is in the EnrolleeIndividual’s best interest. Expedited authorization decisions are those in which a provider indicates or If the Contractor determines that following extends the standard authorization decision timeframe could seriously jeopardize past fourteen (14) calendar days of the Enrollee’s life or health or ability to attain, maintain, or regain maximum function. The Contractor must provide decision notice no later than three (3) working days after receipt of the request for service service: The Contractor shall provide the Individual written notice within three (3) Business Days of the Contractor’s decision to extend the timeframe. The notice shall include the reason for an expedited authorization request the decision to extend the timeframe and inform the Individual of the right to file a Grievance if he or she disagrees with a possible extension of up to fourteen (14) additional calendar days if that decision. The Contractor shall issue and carry out its determination as expeditiously as the Enrollee or Individual’s condition requires, and no later than the provider requests an extension or the Contractor justifies to the Division a need for additional information and how date the extension is in the Enrollee’s best interest. Compensation to individuals or utilization management entities must not be structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any Enrolleeexpires.

Authorization of Services. The Contractor will not provide authorization for inpatient hospital services. Providers will continue to seek authorization from the agency’s QIO Contractor. The Contractor must define term “service authorization in request” means a manner that at least includes an EnrolleeGlobal Commitment to Health Waiver enrollee’s request for the provision of a service, or a request by the enrollee’s provider. The Contractor must have in place OVHA shall maintain, and shall require each of its subcontracted Department, to maintain and follow written policies and procedures for the processing of requests for initial and continuing authorizations authorization of medically necessary, covered services. The Contractor policies and procedures must have a mechanism conform to all applicable Federal and State regulations, including specifically 42 CFR 438.210(b). The OVHA may require pre-authorization for certain covered services including, but not limited to, inpatient hospital admissions, home and community based services, and certain pharmaceutical products. For inpatient admissions, specific review criteria for authorization decisions is identified and outlined in the Acute Care Management Program Description policies and procedures manual. The OVHA will ensure consistent application of review criteria for authorization decisions that includes consultation with decisions. Review Criteria shall be incorporated in the requesting provider when appropriate. Any decision to deny a service authorization request 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 appropriate clinical expertise in treating the Enrollee’s condition or disease. The Contractor must notify the requesting provider and the Enrollee in writing of any decision by the Contractor to deny an authorization request or to authorize a service in an amount, duration, or scope that is less than requested. The notice must meet the requirements specified in 42 CFR § 438.404Utilization Management Plan as described above. For standard authorization decisions, the Contractor subcontracted Departments must reach a decision and provide notice within fourteen (14) as expeditiously as the enrollee’s health condition requires and no later than 14 calendar days following from receipt of the request for services service, with a possible extension of up to fourteen (14) 14 additional calendar days if the Enrollee enrollee or provider requests the extension; or the provider requests an extension or the Contractor subcontracted Department justifies to the Division OVHA a need for additional information and how the extension is in the Enrolleeenrollee’s best interest. Expedited authorization decisions are those For cases in which a provider indicates indicates, or the Contractor determines subcontracted Department determines, that following the standard authorization decision timeframe could seriously jeopardize the Enrolleeenrollee’s life or health or ability to attain, maintain, maintain or regain maximum function. The Contractor , the subcontracted Department must make an expedited authorization decision and provide decision notice as expeditiously as the enrollee’s health condition requires and no later than three (3) working days after receipt of the request for service for an expedited authorization request with a possible extension of service. The three days may be extended by up to fourteen (14) 14 additional calendar days if the Enrollee enrollee requests the extension, or if the provider requests an extension or the Contractor subcontracted Department justifies to the Division OVHA a need for additional information and how the extension is in the Enrolleeenrollee’s best interest. Compensation Any case where a decision is not reached within the referenced timeframes constitutes a denial. Written notice must then be issued to individuals or utilization management entities must not be structured so as to provide incentives the enrollee on the date that the timeframe for the individual or entity authorization expires. Planned services will be identified by the authorized clinician working with the enrollee and under the direct supervision of a prescribing provider. Any decision to deny, limitreduce the range, or discontinue medically necessary services suspend covered services, or a failure to approve a service that requires pre- authorization, will constitute grounds for noticing the enrollee. Any disagreement identified by the enrollee at any Enrolleeinterval of evaluation, will also be subject to notice requirements.

Authorization of Services. The Contractor will not provide authorization for inpatient hospital services. Providers will continue to seek authorization from the agency’s QIO Contractor. The Contractor must define term “service authorization in request” means a manner that at least includes an EnrolleeGlobal Commitment to Health Waiver enrollee’s request for the provision of a service, or a request by the enrollee’s provider. The Contractor must have in place DVHA and each of the IGA partners shall maintain and follow written policies and procedures for the processing of requests for initial and continuing authorizations authorization of medically necessary, covered services. The Contractor policies and procedures must have a mechanism conform to all applicable Federal and State regulations, including specifically 42 CFR 438.210(b). DVHA and each of the IGA partners may require pre-authorization for certain covered services including, but not limited to, inpatient hospital admissions, home and community based services, and certain pharmaceutical products. Should DVHA or its IGA partners exercise the prior authorization option, review criteria for authorization decisions will be identified for providers. DVHA or its IGA partners will ensure consistent application of review criteria for authorization decisions that includes consultation with the requesting provider when appropriatedecisions. Any decision to deny a service authorization request 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 appropriate clinical expertise in treating the Enrollee’s condition or disease. The Contractor must notify the requesting provider and the Enrollee in writing of any decision by the Contractor to deny an authorization request or to authorize a service in an amount, duration, or scope that is less than requested. The notice must meet the requirements specified in 42 CFR § 438.404. • For standard authorization decisions, the Contractor IGA partners must reach a decision and provide notice within fourteen (14) as expeditiously as the enrollee’s health condition requires and no later than 14 calendar days following from receipt of the request for services service, with a possible extension of up to fourteen (14) 14 additional calendar days if the Enrollee enrollee or provider requests the extension; or the provider requests an extension or the Contractor IGA partner justifies to the Division DVHA a need for additional information and how the extension is in the Enrolleeenrollee’s best interest. Expedited authorization decisions are those • For cases in which a provider indicates indicates, or the Contractor determines IGA partner determines, that following the standard authorization decision timeframe could seriously jeopardize the Enrolleeenrollee’s life or health or ability to attain, maintain, maintain or regain maximum function. The Contractor , the IGA partner must make an expedited authorization decision and provide decision notice as expeditiously as the enrollee’s health condition requires and no later than three (3) working days after receipt of the request for service for an expedited authorization request with a possible extension of service. The three days may be extended by up to fourteen (14) 14 additional calendar days if the Enrollee enrollee requests the extension, or if the provider requests an extension or the Contractor IGA partner justifies to the Division DVHA a need for additional information and how the extension is in the Enrolleeenrollee’s best interest. Compensation Any case where a decision is not reached within the referenced timeframes constitutes a denial. Written notice must then be issued to individuals or utilization management entities must not be structured so as to provide incentives the enrollee on the date that the timeframe for the individual or entity authorization expires. Untimely service authorizations constitute a denial and are thus adverse actions. Planned services will be identified by the authorized clinician working with the enrollee and under the direct supervision of a prescribing provider. Any decision to deny, limitreduce the range, or discontinue medically necessary suspend covered services, or a failure to approve a service that requires pre-authorization, will constitute grounds for noticing the enrollee. Any disagreement identified by the enrollee at any interval of evaluation, will also be subject to notice requirements. Notices must meet language and format requirements set forth in 42 CFR §438.404 Notice must be given within the timeframes set forth above, except that notice may be given on the date of action under the following circumstances: • Signed written enrollee statement requesting service termination; • Signed written enrollee statement requesting new service or range increase; • A enrollee’s admission to an institution where he or she is ineligible for further services; • A enrollee’s address is unknown and mail directed to him or her has no forwarding address; • The enrollee’s physician prescribes the change in the range of clinical need. DVHA or its IGA partners shall notify the requesting provider and issue written notices to enrollees for any decision to deny a service, or to authorize a service in an amount, scope or duration less than that requested and clinically prescribed in the service plan. Notices must explain the action DVHA or the IGA partner has taken or intends to take; the reasons for the action; the enrollee’s right to file an appeal and procedures for doing so; circumstances under which an expedited resolution is available and how to request one; the enrollee’s right at any time to request a Fair Hearing for covered services and how to any Enrolleerequest that covered services be extended; the enrollee’s right to request external review by DVHA/AHS for covered services (as applicable to Medicaid eligibility) or alternate services; and the circumstances under which the enrollee may be required to pay the costs of those services pending the outcome of a Fair Hearing or external review by DVHA/AHS.

Authorization of Services. The Contractor will not provide LME/PIHP shall determine medical necessity for those services requiring prior authorization for inpatient hospital servicesas set forth in Controlling Authority, including DMA Clinical Coverage Policies. Providers will continue to seek authorization from For those services requiring prior authorization, the agency’s QIO Contractor. The Contractor must define service authorization in LME/PIHP shall issue a manner that at least includes an Enrollee’s request for the provision of a service. The Contractor must have in place written policies and procedures for the processing of requests for initial and continuing authorizations of services. The Contractor must have a mechanism to ensure consistent application of review criteria for authorization decisions that includes consultation with the requesting provider when appropriate. Any decision to approve or deny a service authorization request 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 appropriate clinical expertise in treating the Enrollee’s condition or disease. The Contractor must notify the requesting provider and the Enrollee in writing of any decision by the Contractor to deny an authorization request or to authorize a service in an amount, duration, or scope that is less than requested. The notice must meet the requirements specified in 42 CFR § 438.404. For standard authorization decisions, the Contractor must provide notice within fourteen (14) calendar days following after receipt of the request request, provided that the deadline may be extended for services with a possible extension of up to fourteen (14) additional calendar days if if: The Enrollee requests the Enrollee extension; or The CONTRACTOR requests the provider requests an extension extension; or the Contractor The LME/PIHP justifies to the Division a Department upon request: A need for additional information information; and how How the extension is in the Enrollee’s best interest. Expedited In those cases for services requiring prior authorization decisions are those in which a provider indicates CONTRACTOR indicates, or the Contractor determines LME/PIHP determines, that following adherence to the standard authorization decision timeframe could seriously jeopardize the an Enrollee’s life or health or ability to attain, maintain, or regain maximum function. The Contractor must provide , including but not limited to psychiatric inpatient hospitalization services, LME/PIHP shall issue a decision notice no later than to approve or deny a service within three (3) working calendar days after receipt of it receives the request for service services, provided that the deadline may be extended for an expedited authorization request with a possible extension of up to fourteen (14) additional calendar days if if: The Enrollee requests the Enrollee extension; or the provider requests an extension or the Contractor The LME/PIHP justifies to the Division a Department upon request: A need for additional information information; and how How the extension is in the Enrollee’s best interest. Compensation For those services requiring prior authorization, the LME/PIHP shall permit retroactive authorization of such services in instances where the Enrollee has been retroactively enrolled in the Medicaid program or in the LME/PIHP program, or where the Enrollee has primary insurance which has not yet paid or denied its claim. Retroactive authorizations include requests for deceased Enrollees. The request for authorization must be submitted within ninety (90) days of primary denial or notice of enrollment. Upon the denial of a requested authorization, the LME/PIHP shall inform Enrollee’s attending physician or ordering provider of the availability of a peer to individuals peer conversation, to be conducted within one business day. For appeal information, please refer to the LME/PIHP Provider Operations Manual. In conducting prior authorization, LME/PIHP shall not require CONTRACTOR to resubmit any data or utilization management entities must not be structured so as documents previously provided to provide incentives LME/PIHP for the individual or entity to deny, limit, or discontinue medically necessary services to any Enrollee’s presently authorized services.

Authorization of Services. The Contractor will not provide authorization for inpatient hospital services. Providers will continue to seek authorization from the agency’s UM/QIO Contractor. The Contractor must define service authorization in a manner that at least includes an Enrollee’s request for the provision of a service. The Contractor must have in place written policies and procedures for the processing of requests for initial and continuing authorizations of services. The Contractor must have a mechanism to ensure consistent application of review criteria for authorization decisions that includes consultation with the requesting provider when appropriate. Any decision to deny a service authorization request 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 appropriate clinical expertise in treating the Enrollee’s condition or disease. The Contractor must notify the requesting provider and the Enrollee in writing of any decision by the Contractor to deny an authorization request or to authorize a service in an amount, duration, or scope that is less than requested. The notice must meet the requirements specified in 42 CFR § 438.404. For standard authorization decisions, the Contractor must provide notice within fourteen (14) calendar days following receipt of the request for services with a possible extension of up to fourteen (14) additional calendar days if the Enrollee or the provider requests an extension or the Contractor justifies to the Division a need for additional information and how the extension is in the Enrollee’s best interest. Expedited authorization decisions are those in which a provider indicates or the Contractor determines that following the standard authorization decision timeframe could seriously jeopardize the Enrollee’s life or health or ability to attain, maintain, or regain maximum function. The Contractor must provide decision notice no later than three (3) working days after receipt of the request for service for an expedited authorization request with a possible extension of up to fourteen (14) additional calendar days if the Enrollee or the provider requests an extension or the Contractor justifies to the Division a need for additional information and how the extension is in the Enrollee’s best interest. Compensation to individuals or utilization management entities must not be structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any Enrollee.

Authorization of Services. The Contractor will not provide authorization for inpatient hospital services. Providers will continue to seek authorization from the agency’s QIO Contractor. The Contractor must define service authorization in a manner that at least includes an Enrollee’s request for the provision of a service. The Contractor must have in place written policies and procedures for the processing of requests for initial and continuing authorizations of services. The Contractor must have a mechanism to ensure consistent application of review criteria for authorization decisions that includes consultation with the requesting provider when appropriate. Any decision to deny a service authorization request 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 appropriate clinical expertise in treating the Enrollee’s condition or disease. The Contractor must notify the requesting provider and the Enrollee in writing of any decision by the Contractor to deny an authorization request or to authorize a service in an amount, duration, or scope that is less than requested. The notice must meet the requirements specified in 42 CFR § Section 438.404. For standard authorization decisions, the Contractor must provide notice within fourteen (14) calendar days following receipt of the request for services with a possible extension of up to fourteen (14) additional calendar days if the Enrollee or the provider requests an extension or the Contractor justifies to the Division a need for additional information and how the extension is in the Enrollee’s best interest. Expedited authorization decisions are those in which a provider indicates or the Contractor determines that following the standard authorization decision timeframe could seriously jeopardize the Enrollee’s life or health or ability to attain, maintain, or regain maximum function. The Contractor must provide decision notice no later than three (3) working days after receipt of the request for service for an expedited authorization request with a possible extension of up to fourteen (14) additional calendar days if the Enrollee or the provider requests an extension or the Contractor justifies to the Division a need for additional information and how the extension is in the Enrollee’s best interest. Compensation to individuals or utilization management entities must not be structured so as to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any Enrollee.