General Requirements

90.1 – General Requirements (Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11) PFFS plans are prohibited from restricting a members’ access to services by requiring prior authorization, prior notification, or referrals as a condition of coverage when medically necessary, plan-covered services are furnished to members. However, members and providers have the right to request a written advance organization determination from the plan, in accordance with Subpart M of Part 422, before a member receives a service in order to confirm that the service is medically necessary and will be covered by the plan. Refer to section 100 of this chapter for information on advance organization determinations. The requirements described below apply to all three types (full, partial, and non-network) of PFFS plans.