Time Frames for Notice of Decisions a. The PH-MCO must process each request for Prior Authorization of a service and notify the Member of the decision as expeditiously as the Member’s health condition requires, or at least orally, within two (2) Business Days of receiving the request, unless additional information is needed. If no additional information is needed, the PH-MCO must mail written notice of the decision to the Member, the Member’s PCP, and the prescribing Provider within two (2) Business Days after the decision is made. The PH-MCO may make notification of coverage approvals via electronic notices as permitted under 28 Pa. Code 9.753(b). If additional information is needed to make a decision, the PH-MCO must request such information from the appropriate Provider within forty-eight (48) hours of receiving the request and allow fourteen (14) days for the Provider to submit the additional information. If the PH-MCO requests additional information, the PH-MCO must notify the Member on the date the additional information is requested, using the template, N(7) Request for Additional Information Letter available in Docushare.
Time Frames for Notice of Decisions a. The CHC-MCO must process each request for Prior Authorization and notify the Participant of the decision as expeditiously as the Participant’s health condition requires, or at least orally, within two (2) business days of receiving the request, unless additional information is needed. If no additional information is needed, the CHC-MCO must mail written notice of the decision to the Participant, the Participant’s PCP, and the prescribing Provider within two (2) business days after the decision is made. The CHC- MCO may make notification of coverage approvals via electronic notices as permitted under 28 Pa. Code § 9.753(b). If additional information is needed to make a decision, the CHC-MCO must request such information from the appropriate Provider within two (2) business days of receiving the request and allow fourteen (14) days for the Provider to submit the additional information. If the CHC-MCO requests additional information, the CHC-MCO must notify the Participant on the date the additional information is requested, using the template provided by the Department, Request for Additional Information Letter.
Time Frames for Notice of Decisions a. The CHC-MCO must process each request for Prior Authorization and notify the Participant of the decision as expeditiously as the Participant’s health condition requires, or at least orally, within two (2) business days of receiving the request, unless additional information is needed. If no additional information is needed, the CHC-MCO must mail written notice of the decision to the Participant, the Participant’s PCP, and the prescribing Provider within two (2) business days after the decision is made. The CHC- MCO may make notification of coverage approvals via electronic notices as permitted under 28 Pa. Code § 9.753(b). The two (2) business day decision timeframe for physical health services requests begins on the date the prescribing provider submits the request. The two (2) business day notification timeframe for HCBS requests begins on the date that the updated PCSP is finalized as a result of the assessment, or when an assessment is not necessary, on the date the request is made by the Participant or Participant’s representative, which may include the Participant’s Provider, or the Participant’s Service Coordinator. If additional information is needed to make a decision, the CHC-MCO must request such information from the appropriate Provider within two (2) business days of receiving the request and allow fourteen (14) days for the Provider to submit the additional information. If the CHC-MCO requests additional information, the CHC-MCO must notify the Participant on the date the additional information is requested, using the template provided by the Department, Request for Additional Information Letter. Timeframes specific to home/vehicle modifications or pest eradication decisions are addressed in Section V.B.3.
Time Frames for Notice of Decisions a. The PH-MCO must process each request for Prior Authorization of a service and notify the Member of the decision as expeditiously as the Member’s health condition requires, or at least orally, within two (2) Business Days of receiving the request, unless additional information is needed. If no additional information is needed, the PH-MCO must mail written notice of the decision to the Member, the Member’s PCP, and the prescribing Provider within two (2) Business Days after the decision is made. The PH-MCO may make notification of coverage approvals via electronic notices as permitted under 28 Pa. Code 9.753(b). If additional information is needed to make a decision, the PH-MCO must request such information from the appropriate Provider within forty-eight (48) hours of receiving the request and allow fourteen (14) days for the Provider to submit the additional information. If the PH-MCO requests additional information, the PH-MCO must notify the Member on the date the additional information is requested, using the template, N(7) Request for Additional Information Letter available in Docushare.
b. If the requested information is provided within fourteen (14) days, the PH-MCO must must contact the prescribing provider at least once to confirm all available documentation pertaining to the requested service has been submitted and document the contact in the members case record before making a decision to approve or deny the service, and notify the Member orally, within two (2) Business Days of receipt of the additional information. The PH- MCO must mail written notice of the decision to the Member, the Member’s PCP, and the prescribing Provider within two (2) Business Days after the decision is made.
c. If the requested information is not received within fourteen (14) days, the PH-MCO must contact the prescribing provider at least once to confirm all available documentation pertaining to the requested service has been submitted and document the contact in the members case record before making a decision to approve or deny the service based upon the available information and notify the Member orally within two (2) Business Days after the additional information was to have been received. The PH-MCO must mail written notice of the decision to the Member, the Member’s PCP, and the prescribing Provider within two (2) Business Days after the decision is made.
d. In all cases, the PH-MCO must make the decision to approve or deny a covered service or item and the Mem...
Time Frames for Notice of Decisions. The PH-MCO must process each request for Prior Authorization of a service and notify the Member of the decision as expeditiously as the Member’s health condition requires, or at least orally, as follows:
