Common use of Standard Service Authorization Decisions Clause in Contracts

Standard Service Authorization Decisions. i. For Family Care and Partnership, standard service authorization decisions shall be made no later than fourteen (14) calendar days following receipt of the request for the service unless the MCO extends the timeframe for up to fourteen (14) additional calendar days. If the timeframe is extended, the MCO must send a written notification to the member no later than the fourteenth day after the original request The notification of extension must inform the member that: a) The member may file a grievance if dissatisfied with the extension, in which case the extension will be considered a denial, and b) The member may contact the Member Rights Specialist for assistance. ii. For PACE, decisions on direct requests for services must be made and notice provided as expeditiously as the member’s health condition requires but not more than 72 hours after the date the interdisciplinary team receives the request. The interdisciplinary team may extend this 72-hour timeframe by up to five (5) additional calendar days for either of the following reasons: a) The participant or legal decision maker requests the extension, or b) The team documents its need for additional information and how the delay is in the interest of the participant.

Standard Service Authorization Decisions. i. For Family Care and Partnership, standard service authorization decisions shall be made no later than fourteen (14) calendar days following receipt of the request for the service unless the MCO extends the timeframe for up to fourteen (14) additional calendar days. If the timeframe is extended, the MCO must send a written notification to the member no later than the fourteenth day after the original request The notification of extension must inform the member that: a) The member may file a grievance if dissatisfied with the extension, in which case the extension will be considered a denial, and b) The member may contact the Member Rights Specialist for assistance. ii. For PACE, decisions on direct requests for services must be made and notice provided as expeditiously as the member’s health condition requires but not more than 72 hours after the date the interdisciplinary team receives the request. The interdisciplinary team may extend this 72-hour timeframe by up to five (5) additional calendar days for either of the following reasons: a) The participant or legal decision maker designated authorized representative requests the extension, or b) The team documents its need for additional information and how the delay is in the interest of the participant.