Continuation of Disputed Services During Expedited Appeals. The Contractor shall continue the Enrollee’s disputed services during the expedited Appeal if:
(1) the Adverse Benefit Determination being appealed is to reduce, suspend or terminate a previously authorized course of treatment;
(2) the services were ordered by an authorized Provider;
(3) the period covered by the original authorization has not expired;
(4) the Enrollee or the Enrollee’s legal guardian or other authorized representative files a request for continuation of disputed services, and files timely, which means filing the request on or before the later of the following:
(i) within 10 calendar days of the Contractor sending the Notice of Adverse Benefit Determination; or
(ii) by the intended effective date of the Contractor’s proposed Adverse Benefit Determination.
Continuation of Disputed Services During Expedited Appeals. In accordance with 42 CFR § 438.420, 42 CFR § 438.404(b)(6), and 42 CFR § 431.230(b), the Contractor shall continue the Enrollee’s disputed services during the expedited Appeal if:
(1) the Adverse Benefit Determination is to reduce, suspend, or terminate a previously authorized course of treatment;
(2) the services were ordered by an authorized Provider;
(3) the period covered by the original authorization has not expired; and
(4) the Enrollee files a request for continuation of disputed services timely, which means filing on or before the later of the following:
(i) within 10 calendar days of the Contractor sending the Notice of Adverse Benefit Determination; or
(ii) by the intended effective date of the Contractor’s proposed Adverse Benefit Determination.
