Common use of Service Authorization Decisions Not Reached Within Required Time Frames Clause in Contracts

Service Authorization Decisions Not Reached Within Required Time Frames. In the event that the Contractor fails to make a Service Authorization decision within the proscribed time frames, such failure shall constitute a denial of services and shall be considered an adverse Action. The Contractor is required send out a Notice of Action to the Enrollee and the Provider on the day that the time frame expires. 7.1.6 Decisions to Terminate, Suspend, or Reduce Previously Authorized Covered Services (A) If the Contractor terminates, suspends or reduces previously authorized Covered Services this constitutes an Action. The Contractor shall notify the requesting Provider and mail a Notice of Action to the Enrollee as expeditiously as the Enrollee’s health condition requires and within the following time frames: (1) At least 10 days prior to the date of the Action; or (2) Five days before the date of the Action if the Contractor has facts indicating that the Action should be taken because of probable Fraud by the Enrollee, and the facts have been verified, if possible, through secondary sources; or (3) by the date of the Action if: (i) the Contractor has factual information confirming the death of the Enrollee; (ii) the Contractor receives a clear, written statement from the Enrollee that: (a) the Enrollee no longer wants the services; or (b) the Enrollee gives information that requires termination or reduction of services and indicates that he or she understands that this shall be the result of supplying that information; (4) the Enrollee has been admitted to an institution where he is ineligible for further services; (5) the Enrollee’s whereabouts are unknown and the post office returns mail directed to him indicating no forwarding address. In this case any discontinued services shall be reinstated if his whereabouts become known during the time he is eligible for services; (6) the Enrollee has been accepted for Medicaid services by another local jurisdiction; or (7) the Enrollee’s physician prescribes the change in the level of medical care.