40 4. Understand the Prior Authorization Process. A. Timing of Request. Prior Authorization requests should be made to the Care Coordinators at least three business days before a scheduled service, treatment, procedure, inpatient admission or any other service requiring Prior Authorization except in the following circumstances: • For an “emergency” hospital admission or outpatient procedure, notification to the Care Coordinators should be made on or before the next business day after the admission or procedure. For the purposes of this subsection only, “emergency” is defined as a procedure that has not been previously scheduled and cannot be delayed without harming your health. • Notification should be made upon your identification as a potential organ or tissue transplant recipient. • Maternity admission notifications should be submitted thirty (30) days before the expected delivery date. B. Submission of a Request. You are ultimately responsible for ensuring that all Prior Authorizations are approved and on file prior to the provision of service to maximize benefits under the Plan. Most Prior Authorization requests are submitted to the Care Coordinators by a designated PCP, other PCP, or other healthcare provider via the Plan’s provider portal, facsimile or by calling the Care Coordinators: 1-866-871-0839 as listed on the back of your identification card. C. Evaluation of the Request Submitted Prior Authorization requests considered Pre-service Claims are reviewed to determine if the requested service is: (a) specifically covered or excluded under the terms of the Plan or (b) considered experimental or investigative and (c) medically necessary under the Plan’s Medical Management Standards discussed below. Depending on the request, the Care Coordinators may contact the requesting provider and/or treating provider to obtain additional clinical information to support the request and will suspend the claim for 45 days to allow the provider to send the information. At the end of the 45-day period, the claim will be denied as an administrative denial if the information is not provided. D. Ongoing Courses of Treatment. Quantum Health will regularly monitor inpatient hospital stays, other institutional admissions, or ongoing courses of treatment if you are receiving ongoing care and will examine the use of alternative levels of care or facilities, if necessary, under the appropriate Medical Management Standards. Quantum Health will communicate regularly with attending providers, discharge planners of facilities, and you and/or your family to monitor your progress and expect and initiate planning for discharge needs. If Quantum Health reduces or terminates an already approved courses of treatment or is reviewing an ongoing course of treatment in a Claim involving urgent care, the Claim will be treated as a Concurrent care Claim under the Plan’s Claim and Appeal Procedures. Otherwise, it will be treated as a Pre-service or Post-service Claim as applicable.