Notification of Coverage and Authorization Determinations. For all authorization determinations, the Contractor must notify the ordering provider, requesting facility, and the Enrollee in writing. The Contractor must follow all timeframes outlined in the Timeframes for Authorization Decisions and Notification of Coverage and Authorization Determinations sections of the IFC contract. The notice 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 the Enrollee has any liability for payment. Information regarding whether and how the Enrollee may Appeal the decision. The Enrollee’s right to receive the Contractor’s assistance in filing an Appeal and how to request it, including access to services for Enrollees with communication barriers or disabilities.
Notification of Coverage and Authorization Determinations. For all Actions and adverse authorization determinations, which includes denial of a Contracted Service based on lack of Available Resources, the Contractor must notify the ordering provider, facility, and the Enrollee. The Contractor must inform the parties, other than the Enrollee, in advance whether it will provide notification by phone, mail, fax or other means. The Contractor must notify the Enrollee in writing of the decision. For an adverse authorization decision involving an expedited authorization request the Contractor may initially provide notice orally. For all adverse authorization decisions, the Contractor shall provide written notification within seventy-two (72) hours of the decision. The Contractor shall give notice at least ten (10) calendar days before the effective date of adverse authorization determination when it involves a termination, suspension or reduction of previously authorized Contracted Services when Enrollee Fraud has been verified. Compliance with Office of the Insurance Commissioner Regulations
Notification of Coverage and Authorization Determinations. 11.5.1 For all Actions the Contractor shall notify the individual in writing and the requesting provider or facility orally or 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.
Notification of Coverage and Authorization Determinations. 11.6.1 For all Adverse Benefit Determinations, the Contractor must notify the Enrollee in writing, using an HCA-developed template, and the ordering provider or facility orally or in writing. The Contractor must notify the parties, other than the Enrollee, in advance whether it will provide notification by phone, mail, fax, or other means. Adverse Benefit Determinations Involving an Expedited Authorization: The Contractor must notify the Enrollee in writing of the decision. The Contractor may initially provide notice orally to the Enrollee or the requesting provider within seventy-two (72) hours of the request. The Contractor will send the written notice no later than seventy-two (72) hours after receipt of the request for service. The Contractor will notify the requesting provider and give the Enrollee written notice of any decision by the Contractor to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less than requested. The notice will meet the following requirements (42 C.F.R. § 438.210(c) and 438.404):
