Common use of Time Frames and Procedures for Expedited Service Authorization Decisions Clause in Contracts

Time Frames and Procedures for Expedited Service Authorization Decisions. (A) For cases in which a Provider indicates, or the Contractor determines (on request from an Enrollee) that following the standard time frame could seriously jeopardize the Enrollee’s life or health or ability to attain, maintain, or regain maximum function, the Contractor shall: (1) Make an expedited Service Authorization decision and provide notice as expeditiously as the Enrollee’s health condition requires, but no later than three working days after the receipt of the request for Service Authorization; (i) The Contractor may extend the three working day time period by up to 14 calendar days if: (a) the Enrollee requests the extension; or (b) the Contractor justifies (to the Department upon request) a need for additional information and how the extension is in the Enrollee’s interest. (B) If the Contractor denies an expedited Service Authorization Request, or authorizes a requested service in an amount, duration or scope that is less than requested, the contractor shall follow the notification requirements found in Article 7.1.3.

Time Frames and Procedures for Expedited Service Authorization Decisions. (A) For cases in which a Provider indicates, or the Contractor determines (on request from an Enrollee) that following the standard time frame could seriously jeopardize the Enrollee’s life or health or ability to attain, maintain, or regain maximum function, the Contractor shall: (1) Make an expedited Service Authorization decision and provide notice as expeditiously as the Enrollee’s health condition requires, but no later than three working days 72 hours after the receipt of the request for Service AuthorizationAuthorization Request; (i) The Contractor may extend the three working day 72 hour time period by up to 14 calendar days if: (a) the Enrollee requests the extension; or (b) the Contractor justifies (to the Department upon request) a need for additional information and how the extension is in the Enrollee’s interest. (B) If the Contractor denies an expedited Service Authorization Request, or authorizes a requested service in an amount, duration or scope that is less than requested, the contractor Contractor shall follow the notification requirements found in Article 7.1.3.