Common use of Care Management Clause in Contracts

Care Management. Care Management services work to help ensure that you receive appropriate and cost-effective medical care. Your role in the Care Management process is simple, but important, as explained below. You must be eligible on the dates of service and services must be medically necessary. We encourage you to call Customer Service to verify that you meet the required criteria for claims payment and to help us identify admissions that might benefit from case management. PRIOR AUTHORIZATION Your coverage for some services depends on whether the service is approved before you receive it. This process is called prior authorization. A planned service is reviewed to make sure it is medically necessary and eligible for coverage under this plan. We will let you know in writing if the service is authorized. We will also let you know if the services are not authorized and the reasons why. If you disagree with the decision, you can request an appeal. See Complaints and Appeals or call us. There are three situations where prior authorization is required:  Before you receive certain medical services and drugs, or prescription drugs  Before you schedule a planned admission to certain inpatient facilities  When you want to receive benefits for services from an out-of-network provider How to Ask for Prior Authorization The plan has a specific list of services that must have prior authorization with any provider. The list is on our website at xxxxxxxxxx.xxx. Before you receive services, we suggest that you review the list of services requiring prior authorization. LifeWise Connect providers will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services. Generally this plan does not cover services from providers not in the LifeWise Connect network. If there is not a LifeWise Connect provider that can provide the service needed, see Services from Out-of-Network Providers for more information. We will respond to a request for prior authorization within 5 calendar days of receipt of all information necessary to make a decision. If your situation is clinically urgent (meaning that your life or health would be put in serious jeopardy if you did not receive treatment right away), you may request an expedited review. Expedited reviews are responded to as soon as possible, but no later than 48 hours after we get the all information necessary to make a decision. We will provide our decision in writing. Our prior authorizations will be valid for 30 calendar days. This 30-day period is subject to your continued coverage under the plan. If you do not receive the services within that time, you will have to ask us for another prior authorization. Prior Authorization Penalty For Services from In-Network and Contracted Providers Providers that have contracts with us will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services.

Care Management. Care Management services work to help ensure that you receive appropriate and cost-effective medical care. Your role in the Care Management process is simple, but important, as explained below. You must be eligible on the dates of service and services must be medically necessary. We encourage you to call Customer Service to verify that you meet the required criteria for claims payment and to help us identify admissions that might benefit from case management. PRIOR AUTHORIZATION Your coverage for some services depends on whether the service is approved before you receive it. This process is called prior authorization. A planned service is reviewed to make sure it is medically necessary and eligible for coverage under this plan. We will let you know in writing if the service is authorized. We will also let you know if the services are not authorized and the reasons why. If you disagree with the decision, you can request an appeal. See Complaints and Appeals or call us. There are three situations where prior authorization is required:  • Before you receive certain medical services and drugs, or prescription drugs  • Before you schedule a planned admission to certain inpatient facilities  • When you want to receive benefits for services from an out-of-network provider How to Ask for Prior Authorization The plan has a specific list of services that must have prior authorization with any provider. The list is on our website at xxxxxxxxxx.xxxxxxxxxx.xxx. Before you receive services, we suggest that you review the list of services requiring prior authorization. LifeWise Connect Your PCP or referred Heritage Signature providers will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services. Generally this plan does not cover services from providers not in the LifeWise Connect Heritage Signature network. If there is not a LifeWise Connect Heritage Signature provider that can provide the service needed, see Services from Out-of-Network Providers for more information. We will respond to a request for prior authorization within 5 calendar days of receipt of all information necessary to make a decision. If your situation is clinically urgent (meaning that your life or health would be put in serious jeopardy if you did not receive treatment right away), you may request an expedited review. Expedited reviews are responded to as soon as possible, but no later than 48 hours after we get the all information necessary to make a decision. We will provide our decision in writing. Our prior authorizations will be valid for 30 calendar days. This 30-day period is subject to your continued coverage under the plan. If you do not receive the services within that time, you will have to ask us for another prior authorization. Prior Authorization Penalty For Services from In-Network and Contracted Providers Providers that have contracts with us will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services.

Care Management. Care Management services work to help ensure that you receive appropriate and cost-effective medical care. Your role in the Care Management process is simple, but important, as explained below. You must be eligible on the dates of service and services must be medically necessary. We encourage you to call Customer Service to verify that you meet the required criteria for claims payment and to help us identify admissions that might benefit from case management. PRIOR AUTHORIZATION Your coverage for some services depends on whether the service is approved before you receive it. This process is called prior authorization. A planned service is reviewed to make sure it is medically necessary and eligible for coverage under this plan. We will let you know in writing if the service is authorized. We will also let you know if the services are not authorized and the reasons why. If you disagree with the decision, you can request an appeal. See Complaints and Appeals or call us. There are three situations where prior authorization is required:  Before you receive certain medical services and drugs, or prescription drugs  Before you schedule a planned admission to certain inpatient facilities  When you want to receive benefits for services from an out-of-network provider How to Ask for Prior Authorization The plan has a specific list of services that must have prior authorization with any provider. The list is on our website at xxxxxxxxxx.xxxxxxxxxx.xxx. Before you receive services, we suggest that you review the list of services requiring prior authorization. LifeWise Connect Your PCP or referred Heritage Signature providers will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services. Generally this plan does not cover services from providers not in the LifeWise Connect Heritage Signature network. If there is not a LifeWise Connect Heritage Signature provider that can provide the service needed, see Services from Out-of-Network Providers for more information. We will respond to a request for prior authorization within 5 calendar days of receipt of all information necessary to make a decision. If your situation is clinically urgent (meaning that your life or health would be put in serious jeopardy if you did not receive treatment right away), you may request an expedited review. Expedited reviews are responded to as soon as possible, but no later than 48 hours after we get the all information necessary to make a decision. We will provide our decision in writing. Our prior authorizations will be valid for 30 calendar days. This 30-day period is subject to your continued coverage under the plan. If you do not receive the services within that time, you will have to ask us for another prior authorization. Prior Authorization Penalty For Services from In-Network and Contracted Providers Providers that have contracts with us will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services.

Care Management. Care Management services work to help ensure that you receive appropriate and cost-effective medical care. Your role in the Care Management process is simple, but important, as explained below. You must be eligible on the dates of service and services must be medically necessary. We encourage you to call Customer Service to verify that you meet the required criteria for claims payment and to help us identify admissions that might benefit from case management. PRIOR AUTHORIZATION Your coverage for some services depends on whether the service is approved by us before you receive it. This process is called prior authorization. A planned service is reviewed to make sure it is medically necessary and eligible for coverage under this plan. We will let you know in writing if the service is authorized. We will also let you know if the services are not authorized and the reasons why. If you disagree with the decision, you can request an appeal. See Complaints and Appeals or call us. There are three situations where prior authorization is required:  Before you receive certain medical services and drugs, or prescription drugs  Before you schedule a planned admission to certain inpatient facilities  When you want to receive benefits for services you received from an out-of-network provider How to Ask for Prior Authorization The plan has a specific list of services that must have prior authorization with any provider. The list is on our website at xxxxxxxxxx.xxx. Before you receive services, we suggest that you review the list of services requiring prior authorization. LifeWise Connect providers will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services. Generally this plan does not cover services from providers not in the LifeWise Connect network. If there is not a LifeWise Connect provider that can provide the service needed, see Services from Out-of-Network Providers for more information. We will respond to a request for prior authorization within 5 calendar days of receipt of all information necessary to make a decision. If your situation is clinically urgent (meaning that your life or health would be put in serious jeopardy if you did not receive treatment right away), you may request an expedited review. Expedited reviews are responded to as soon as possible, but no later than 48 hours after we get the all information necessary to make a decision. We will provide our decision in writing. Our prior authorizations will be valid for 30 calendar days. This 30-day period is subject to your continued coverage under the plan. If you do not receive the services within that time, you will have to ask us for another prior authorization. Prior Authorization Penalty For Services from In-Network and Contracted Providers Providers that have contracts with us will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services.

Care Management. Care Management services work to help ensure that you receive appropriate and cost-effective medical care. Your role in the Care Management process is simple, but important, as explained below. You must be eligible on the dates of service and services must be medically necessary. We encourage you to call Customer Service to verify that you meet the required criteria for claims payment and to help us identify admissions that might benefit from case management. PRIOR AUTHORIZATION Your coverage for some services depends on whether the service is approved before you receive it. This process is called prior authorization. A planned service is reviewed to make sure it is medically necessary and eligible for coverage under this plan. We will let you know in writing if the service is authorized. We will also let you know if the services are not authorized and the reasons why. If you disagree with the decision, you can request an appeal. See Complaints and Appeals or call us. There are three situations where prior authorization is required:  • Before you receive certain medical services and drugs, or prescription drugs  • Before you schedule a planned admission to certain inpatient facilities  • When you want to receive benefits for services from an out-of-network provider How to Ask for Prior Authorization The plan has a specific list of services that must have prior authorization with any provider. The list is on our website at xxxxxxxxxx.xxx. Before you receive services, we suggest that you review the list of services requiring prior authorization. LifeWise Connect providers will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services. Generally this plan does not cover services from providers not in the LifeWise Connect network. If there is not a LifeWise Connect provider that can provide the service needed, see Services from Out-of-Network Providers for more information. We will respond to a request for prior authorization within 5 calendar days of receipt of all information necessary to make a decision. If your situation is clinically urgent (meaning that your life or health would be put in serious jeopardy if you did not receive treatment right away), you may request an expedited review. Expedited reviews are responded to as soon as possible, but no later than 48 hours after we get the all information necessary to make a decision. We will provide our decision in writing. Our prior authorizations will be valid for 30 calendar days. This 30-day period is subject to your continued coverage under the plan. If you do not receive the services within that time, you will have to ask us for another prior authorization. Prior Authorization Penalty For Services from In-Network and Contracted Providers Providers that have contracts with us will get a prior authorization for you. You should verify with your provider that a prior authorization request has been approved in writing before you receive services.