US · guidance
CMS Pub. 100-16, ch. mc86c16a, § 90.1
General Requirements
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.
History
(Rev. 99, Issued: 05-27-11, Effective: 05-27-11, Implementation: 05-27-11)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
a944b9b9278e728b6501ab24c7fca7c358dae47ad7ce8fa57a06f5640b2a9ed6
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