Common use of Time Frames for Non-Inpatient Hospital Medical Services Clause in Contracts

Time Frames for Non-Inpatient Hospital Medical Services. The Contractor must notify the requesting Provider and the Member in writing of any decision by the Contractor to deny an authorization request or to authorize a service in an amount, duration, or scope that is less than requested by the treating Provider and/or Member. The notice must meet the requirements specified in 42 C.F.R. § 438.404. Contractor must make standard authorization decisions and provide notice within three (3) calendar days and/or two (2) business days per Minimum Standards for Utilization Review Agents issued by the Mississippi State Department of Health (MSDH) following receipt of the request for services. If Contractor requires additional medical information in order to make a decision, Contractor will notify the requesting provider of additional medical information needed and Contractor must allow three (3) calendar days and/or two (2) business days for the requesting provider to submit the medical information. If Contractor does not receive the additional medical information, Contractor shall make a second attempt to notify the requestor of the additional medical information needed and Contractor must allow one (1) business day or three (3) calendar days for the requestor to submit medical information to Contractor. Once all information is received from the provider, if Contractor cannot make a decision, the three (3) calendar day and/or two (2) business day period may be extended up to fourteen (14) additional calendar days upon request of the Member or the Provider to Contractor, or if Contractor requests an extension from the Division. The extension request to the Division applies only after Contractor has received all necessary medical information to render a decision and Contractor requires additional calendar days to make a decision. The extension request must justify to the Division a need for additional information and explain how the extension is in the Member’s best interest. Any such request is subject to prior approval by the Division. Contractor must provide to the Division the reason(s) justifying the additional calendar days needed to render a decision. The Division will evaluate Contractor’s extension request and notify Contractor of decision within three (3) calendar days and/or two

Time Frames for Non-Inpatient Hospital Medical Services. The Contractor must notify the requesting Provider and the Member in writing of any decision by the Contractor to deny an authorization request or to authorize a service in an amount, duration, or scope that is less than requested by the treating Provider and/or Member. The notice must meet the requirements specified in 42 C.F.R. § 438.404. Contractor must make standard authorization decisions and provide notice within three (3) calendar days and/or two (2) business days per Minimum Standards for Utilization Review Agents issued by the Mississippi State Department of Health (MSDH) following receipt of the request for services. If Contractor requires additional medical information in order to make a decision, Contractor will notify the requesting provider of additional medical information needed and Contractor must allow three (3) calendar days and/or two (2) business days for the requesting provider to submit the medical information. If Contractor does not receive the additional medical information, Contractor shall make a second attempt to notify the requestor of the additional medical information needed and Contractor must allow one (1) business day or three (3) calendar days for the requestor to submit medical information to Contractor. Once all information is received from the provider, if Contractor cannot make a decision, the three (3) calendar day and/or two (2) business day period may be extended up to fourteen (14) additional calendar days upon request of the Member or the Provider to Contractor, or if Contractor requests an extension from the Division. The extension request to the Division applies only after Contractor has received all necessary medical information to render a decision and Contractor requires additional calendar days to make a decision. The extension request must justify to the Division a need for additional information and explain how the extension is in the Member’s best interest. Any such request is subject to prior approval by the Division. Contractor must provide to the Division the reason(s) justifying the additional calendar days needed to render a decision. The Division will evaluate Contractor’s extension request and notify Contractor of decision within three (3) calendar days and/or twotwo (2) business days of receiving Contractor’s request for extension. The Contractor must expedite authorization for services when the Provider indicates or the Contractor determines that following the standard authorization decision time frame could seriously jeopardize the Member’s life, health, or ability to attain, maintain, or regain maximum function. The Contractor must provide decision notice no later than twenty-four (24) hours after receipt of the expedited authorization request. This twenty-four (24) hour period may be extended up to fourteen (14) additional calendar days upon request of the Member, or the Provider, or if Contractor requests an extension from the Division. The extension request to the Division applies only after Contractor has received all necessary medical information to render a decision and Contractor requires additional calendar days to make a decision. The extension request must justify to the Division a need for additional information and explain how the extension is in the Member’s best interest. Any such request is subject to Division approval. The Division will evaluate Contractor’s extension request and notify Contractor of decision within three (3) calendar days and/or two (2) business days of receiving Contractor’s request. The Contractor must justify to the Division a need for additional information and how the extension is in the Member’s best interest. The extension request to the Division applies only after Contractor has received all necessary medical information to render a decision and Contractor requires additional calendar days to make a decision. Contractor must provide to the Division the reason(s) justifying the additional calendar days needed to render a decision. The Division will evaluate Contractor’s extension request and notify Contractor of decision within three (3) calendar days and/or two (2) business days of receiving Contractor’s request for extension.

Time Frames for Non-Inpatient Hospital Medical Services. The Contractor must notify the requesting Provider and the Member in writing of any decision by the Contractor to deny an authorization request or to authorize a service in an amount, duration, or scope that is less than requested by the treating Provider and/or Member. The notice must meet the requirements specified in 42 C.F.R. § 438.404. Contractor must make standard authorization decisions and provide notice within three (3) calendar days and/or two (2) business days per Minimum Standards for Utilization Review Agents issued by the Mississippi State Department of Health (MSDH) following receipt of the request for services. If Contractor requires additional medical information in order to make a decision, Contractor will notify the requesting provider of additional medical information needed and Contractor must allow three (3) calendar days and/or two (2) business days for the requesting provider to submit the medical information. If Contractor does not receive the additional medical information, Contractor shall make a second attempt to notify the requestor of the additional medical information needed and Contractor must allow one (1) business day or three (3) calendar days days) for the requestor to submit medical information to Contractor. Once all information is received from the provider, if Contractor cannot make a decision, the three (3) calendar day and/or two (2) business day period may be extended up to fourteen (14) additional calendar days upon request of the Member or the Provider to Contractor, or if Contractor requests an extension from the Division. The extension request to the Division applies only after Contractor has received all necessary medical information to render a decision and Contractor requires additional calendar days to make a decision. The extension request must justify to the Division a need for additional information and explain how the extension is in the Member’s best interest. Any such request is subject to prior approval by the Division. Contractor must provide to the Division the reason(s) justifying the additional calendar days needed to render a decision. The Division will evaluate Contractor’s extension request and notify Contractor of decision within three (3) calendar days and/or twotwo (2) business days of receiving Contractor’s request for extension. The Contractor must expedite authorization for services when the Provider indicates or the Contractor determines that following the standard authorization decision time frame could seriously jeopardize the Member’s life, health, or ability to attain, maintain, or regain maximum function. The Contractor must provide decision notice no later than twenty-four (24) hours after receipt of the expedited authorization request. This twenty-four (24) hour period may be extended up to fourteen (14) additional calendar days upon request of the Member, or the Provider, or if Contractor requests an extension from the Division. The extension request to the Division applies only after Contractor has received all necessary medical information to render a decision and Contractor requires additional calendar days to make a decision. The extension request must justify to the Division a need for additional information and explain how the extension is in the Member’s best interest. Any such request is subject to Division approval. The Division will evaluate Contractor’s extension request and notify Contractor of decision within three (3) calendar days and/or two (2) business days of receiving Contractor’s request. The Contractor must justify to the Division a need for additional information and how the extension is in the Member’s best interest. The extension request to the Division applies only after Contractor has received all necessary medical information to render a decision and Contractor requires additional calendar days to make a decision. Contractor must provide to the Division the reason(s) justifying the additional calendar days needed to render a decision. The Division will evaluate Contractor’s extension request and notify Contractor of decision within three (3) calendar days and/or two (2) business days of receiving Contractor’s request for extension.