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

Time Frames and Procedures for Denying All or Part of a Service Authorization. (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. (1) The Contractor may extend the time frame for making the decision by up to an additional 14 calendar days if: (i) the Enrollee or the Provider requests an extension; or (ii) the Contractor justifies (to the Department upon request) a need for additional information and how the extension is in the Enrollee’s best interest. (2) If the Contractor extends the time frame for making standard Service Authorization decisions the Contractor shall: (i) Give the Enrollee written notice of the reason for the decision to extend the time frame; (ii) Inform the Enrollee of his or her right to file a Grievance, and how to do so, if the Enrollee disagrees with the decision; and (iii) Issue and carry out the determination as expeditiously as the Enrollee’s health condition requires and no later than the date the extension expires.

Time Frames and Procedures for Denying All or Part of a Service Authorization. (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. (1) The Contractor may extend the time frame for making the decision by up to an additional 14 calendar days if: (i) the Enrollee or the Provider requests an extension; or (ii) the Contractor justifies (to the Department upon request) a need for additional information and how the extension is in the Enrollee’s best interest. (2) If the Contractor extends the time frame for making standard Service Authorization decisions the Contractor shall: (i) Give give the Enrollee written notice of the reason for the decision to extend the time frame; (ii) Inform inform the Enrollee of his or her their right to file a Grievance, and how to do so, if the Enrollee disagrees with the decision; and (iii) Issue issue and carry out the determination as expeditiously as the Enrollee’s health condition requires and no later than the date the extension expires.