Prior Approval Decisions. SAMPLE We will notify you or your representative, and your Provider, of our Prior Approval decisions. Our Prior Approval decisions will discuss whether the requested service is Medically Necessary and is a Covered Service. A denial of coverage based on Medical Necessity (sometimes referred to as an Adverse Health Care Treatment Decision) are initially communicated verbally to the Provider for Exigent Circumstances/Urgent service requests. Written notification is sent to you or your representative and the Provider for Exigent Circumstances/Urgent and routine requests. The written notification cites the reason(s) why the decision was made and includes information about the Appeals process and the right to request in writing copies of any clinical criteria applied in a denial of coverage decision. Additionally, Members will receive written notification of any denial of coverage that is based on non-covered Benefits or Benefit limits that have been reached (known as an Adverse Benefit Determination). The written notification cites the reason(s) why the decision was made and includes information about the Appeals process and the right to request in writing copies of any criteria applied in a denial of coverage decision. Adverse Benefit Determinations also include Claim Denials and are described in section 6.A. For more information on the process for appealing Adverse Health Care Treatment Decisions or Adverse Benefit Determinations, please see section 8, Appeals and Complaints. A request by a provider for Prior Approval of routine medical and behavioral health services and formulary drugs requiring Prior Approval will be reviewed within 72 hours or two (2) business days, whichever is less. If the provider has not submitted all necessary information, Health Options will request additional information within this timeframe. The provider has two (2) business days to submit information. At the end of the two business days or upon receipt of the requested information (whichever is less), a decision will be made within 72 hours or (2) business days (whichever is less) based on submitted information. A request by a provider regarding Exigent Circumstances for concurrent medical services (ongoing care such as an inpatient admission) requests will be reviewed within 24 hours or one (1) calendar day. If the provider has not submitted all necessary information, Health Options will request additional information within this timeframe. The Provider has one (1) business day ...
Prior Approval Decisions. We will notify you or your representative, and your Provider, of our Prior Approval decisions. Our Prior Approval decisions will discuss whether the requested service is Medically Necessary and is a Covered Service. A denial of coverage based on Medical Necessity (sometimes referred to as an Adverse Health Care Treatment Decision) are initially communicated verbally to the Provider for urgent service requests. Written notification is sent to you or your representative and the Provider for urgent routine requests. The written notification cites the reason(s) why the decision was made and includes information about the Appeals process and the right to request in writing copies of any clinical criteria applied in a denial of coverage decision. Additionally, Members will receive written notification of any denial of coverage that is based on non-covered Benefits or Benefit limits that have been reached (known as an Adverse Benefit Determination). The written notification cites the reason(s) why the decision was made and includes information about the Appeals process and the right to request in writing copies of any criteria applied in a denial of coverage decision. Adverse Benefit Determinations also include Claim Denials and are described in section 6.A. For more information on the process for appealing Adverse Health Care Treatment Decisions or Adverse Benefit Determinations, please see section 8, Appeals and Complaints.
