Concurrent Review Authorizations. The Contractor must make its determination within one (1) Business Day of receipt of the request for authorization. Requests to extend concurrent care review authorization determinations may be extended to within three (3) Business Days of the request of the authorization, if the Contractor has made at least one (1) attempt to obtain needed clinical information within the initial one (1) Business Day after the request for authorization of additional days or services. Notification of the Concurrent Review determination shall be made within one (1) Business Day of the Contractor’s decision. Expedited Appeal timeframes apply to Concurrent Review requests. For post-service authorizations, the Contractor shall make its determination within thirty (30) calendar days of receipt of the authorization request. The Contractor shall notify the Individual and the requesting provider within two (2) Business Days of the Contractor’s determination. Standard Appeal timeframes apply to post-service denials. When post-service authorizations are approved they become effective the date the service was first administered. Notification of Coverage and Authorization Determinations For all Actions and other Adverse Authorization Determinations which includes denials of Contracted Services based on the lack of Available Resources, the Contractor shall notify the Individual and the requesting provider in writing. The Contractor must notify all parties, other than the Individual, in advance whether notification will be provided by phone, mail, fax, or other means. For an Adverse Authorization Decision involving an expedited authorization request, the Contractor may initially provide notice orally within seventy-two (72) hours of the request. The Contractor shall provide written notification of the decision within seventy-two (72) hours after receipt of the request for service. Provide notice at least ten (10) calendar days before the effective date of Action or Adverse Authorization Determination when the decision is a termination, suspension or reduction of previously authorized Contracted Services. The notice to the Individual and provider shall explain the following: The decision the Contractor has taken or intends to take. The reasons for the decision, in easily understood language including citation to any Contractor guidelines, protocols, or other criteria that were used to make the decision, and how to access the guidelines, protocols or other criteria. A statement of whether ...
Concurrent Review Authorizations. The Contractor must make its determination within one (1) Business Day of receipt of the request for authorization. Requests to extend concurrent care review authorization determinations may be extended to within three (3) Business Days of the request of the authorization, if the Contractor has made at least one
Concurrent Review Authorizations. The Contractor must make its determination within one (1) business day of receipt of the request for authorization.
