Common use of Time Frames and Procedures for Denying All or Part of a Service Authorization Request Clause in Contracts

Time Frames and Procedures for Denying All or Part of a Service Authorization Request. (A) If the Contractor denies a Service Authorization Request, or authorizes a requested service in an amount, duration or scope that is less than requested, the Contractor shall make the decision and give a Notice of Action to the Enrollee as expeditiously as the Enrollee’s health condition requires it, but no later than 14 calendar days from receipt of the request for Service Authorization. The Contractor shall also notify the requesting Provider, although the notice need not be in writing.

Time Frames and Procedures for Denying All or Part of a Service Authorization Request. (A) If the Contractor denies a Service Authorization Request, or authorizes a requested service in an amount, duration or scope that is less than requested, the Contractor shall make the decision and give a Notice of Action Adverse Benefit Determination to the Enrollee as expeditiously as the Enrollee’s health condition requires it, but no later than 14 calendar days from receipt of the request for Service Authorization. The Contractor shall also notify the requesting Provider, although the notice need not be in writing.