Common use of Time Frames for Notice of Decisions Clause in Contracts

Time Frames for Notice of Decisions. a. The PH-MCO is required to process each request for Prior Authorization (prospective utilization review) of a service and ensure that the Member is notified 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 Business Days after the decision is made. Notification of coverage approvals may also be made via electronic notices 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 supplied by the Department in Exhibit N(7), Request for Additional Information Letter. b. If the requested information is provided within fourteen (14) days, the PH-MCO must make the 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 decision to approve or deny the service must be made based upon the available information and the Member notified 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 decision to approve or deny a covered service or item must be made and the Member must receive written notification of the decision no later than twenty-one (21) days from the date the PH-MCO received the request, or the service or item is automatically approved. To satisfy the twenty-one

Time Frames for Notice of Decisions. a. The PH-MCO is required to must process each request for Prior Authorization (prospective utilization review) of a service and ensure that notify the Member is notified 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. Notification The PH-MCO may make notification of coverage approvals may also be made 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 supplied by the Department in Exhibit template, N(7), ) Request for Additional Information LetterLetter available in Docushare. b. If the requested information is provided within fourteen (14) days, the PH-MCO must make the 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- 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 make the decision to approve or deny the service must be made based upon the available information and notify the Member notified 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 must be made and the Member must receive written notification of the decision no later than twenty-one (21) days from the date the PH-MCO received the request, or the service or item is automatically approved. To satisfy the twentytwenty- one (21) day time period, the PH-oneMCO may mail written notice to the Member, the Member’s PCP, and the prescribing Provider on or before the eighteenth (18th) day from the date the request is received. If the notice is not mailed by the eighteenth (18th) day after the request is received, the PH-MCO must hand deliver the notice to the Member, or the request is automatically approved. e. If the Member is currently receiving a requested service and the PH-MCO decides to deny the Prior Authorization request, the PH- MCO must mail the written notice of denial at least (10) days prior to the effective date of the denial of authorization for continued services. If probable Member fraud has been verified, the period of advance notice is shortened to five (5) days. The PH-MCO is not required to provide advance notice when it has factual information on the following: • confirmation of the death of a Member; • receipt of a clear written statement signed by a Member that she or he no longer wishes services or gives information that requires termination or reduction of services and indicates that she or he understands that termination must be the result of supplying that information; • the Member has been admitted to an institution where she or he is ineligible under the PH-MCO for further services; • the Member’s whereabouts are unknown and the post office returns mail directed to him or her indicating no forwarding address; • the PH-MCO established the fact that the Member has been accepted for MA by another State; or • a change in the level of medical care is prescribed by the Member’s physician.

Time Frames for Notice of Decisions. a. The PH-MCO is required to must process each request for Prior Authorization (prospective utilization review) of a service and ensure that notify the Member is notified 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. Notification The PH-MCO may make notification of coverage approvals may also be made 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 supplied by the Department in Exhibit template, N(7), ) Request for Additional Information LetterLetter available in Docushare. b. If the requested information is provided within fourteen (14) days, the PH-MCO must make 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 must be made based upon the available information and notify the Member notified 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 must be made and the Member must receive written notification of the decision no later than twenty-one (21) days from the date the PH-MCO received the request, or the service or item is automatically approved. To satisfy the twentytwenty- one (21) day time period, the PH-oneMCO may mail written notice to the Member, the Member’s PCP, and the prescribing Provider on or before the eighteenth (18th) day from the date the request is received. If the notice is not mailed by the eighteenth (18th) day after the request is received, the PH-MCO must hand deliver the notice to the Member, or the request is automatically approved. e. If the Member is currently receiving a requested service and the PH-MCO decides to deny the Prior Authorization request, the PH- MCO must mail the written notice of denial at least (10) days prior to the effective date of the denial of authorization for continued services. If probable Member fraud has been verified, the period of advance notice is shortened to five (5) days. The PH-MCO is not required to provide advance notice when it has factual information on the following: • confirmation of the death of a Member; • receipt of a clear written statement signed by a Member that she or he no longer wishes services or gives information that requires termination or reduction of services and indicates that she or he understands that termination must be the result of supplying that information; • the Member has been admitted to an institution where she or he is ineligible under the PH-MCO for further services; • the Member’s whereabouts are unknown and the post office returns mail directed to him or her indicating no forwarding address; • the PH-MCO established the fact that the Member has been accepted for MA by another State; or • a change in the level of medical care is prescribed by the Member’s physician.

Time Frames for Notice of Decisions. a. The PHCHC-MCO is required to must process each request for Prior Authorization (prospective utilization review) of a service and ensure that notify the Member is notified Participant of the decision as expeditiously as the MemberParticipant’s health condition requires, or at least orally, within two (2) Business Days business days of receiving the request, unless additional information is needed. If no additional information is needed, the PHCHC-MCO must mail written notice of the decision to the MemberParticipant, the MemberParticipant’s PCP, and the prescribing Provider within two Business Days (2) business days after the decision is made. Notification The CHC- MCO may make notification of coverage approvals may also be made 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 PHCHC-MCO must request such information from the appropriate Provider within forty-eight two (482) hours business days of receiving the request and allow fourteen (14) days for the Provider to submit the additional information. If the PHCHC-MCO requests additional information, the PHCHC-MCO must notify the Member Participant on the date the additional information is requested, using the template supplied provided by the Department in Exhibit N(7)Department, Request for Additional Information Letter. Timeframes specific to home/vehicle modifications or pest eradication decisions are addressed in Section V.B.3. b. If the requested information is provided within fourteen (14) days, the PH-CHC- MCO must make the decision to approve or deny the service, and notify the Member Participant orally, within two (2) Business Days business days of receipt of the additional information. The PH- CHC-MCO must mail written notice of the decision to the MemberParticipant, the MemberParticipant’s PCP, and the prescribing Provider within two (2) Business Days business days after the decision is made. c. If the requested information is not received within fourteen (14) days, the CHC-MCO must make the decision to approve or deny the service must be made based upon the available information and notify the Member notified Participant 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 decision to approve or deny a covered service or item must be made and the Member must receive written notification of the decision no later than twenty-one (21) days from the date the PH-MCO received the request, or the service or item is automatically approved. To satisfy the twenty-onetwo

Time Frames for Notice of Decisions. ‌ a. The PH-MCO is required to process each request for Prior Authorization (prospective utilization review) of a service and ensure that the Member is notified 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 Business Days after the decision is made. Notification of coverage approvals may also be made via electronic notices 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 supplied by the Department in Exhibit N(7), Request for Additional Information Letter. b. If the requested information is provided within fourteen (14) days, the PH-MCO must make the 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 decision to approve or deny the service must be made based upon the available information and the Member notified 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 decision to approve or deny a covered service or item must be made and the Member must receive written notification of the decision no later than twenty-one (21) days from the date the PH-MCO received the request, or the service or item is automatically approved. To satisfy the twenty-one

Time Frames for Notice of Decisions. ‌ a. The PH-MCO is required to must process each request for Prior Authorization (prospective utilization review) of a service and ensure that notify the Member is notified 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. Notification The PH-MCO may make notification of coverage approvals may also be made 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 supplied by the Department in Exhibit template, N(7), ) Request for Additional Information LetterLetter on the HealthChoices Intranet site. b. If the requested information is provided within fourteen (14) days, the PH-MCO must make the 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 make the decision to approve or deny the service must be made based upon the available information and notify the Member notified 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 must be made and the Member must receive written notification of the decision no later than twenty-one (21) days from the date the PH-MCO received the request, or the service or item is automatically approved. To satisfy the twentytwenty- one (21) day time period, the PH-oneMCO may mail written notice to the Member, the Member’s PCP, and the prescribing Provider on or before the eighteenth (18th) day from the date the request is received. If the notice is not mailed by the eighteenth (18th) day after the request is received, the PH-MCO must hand deliver the notice to the Member, or the request is automatically approved. e. If the Member is currently receiving a requested service and the PH-MCO decides to deny the Prior Authorization request, the PH-MCO must mail the written notice of denial at least (10) days prior to the effective date of the denial of authorization for continued services. If probable Member fraud has been verified, the period of advance notice is shortened to five (5) days. The PH-MCO is not required to provide advance notice when it has factual information on the following: • confirmation of the death of a Member; • receipt of a clear written statement signed by a Member that she or he no longer wishes services or gives information that requires termination or reduction of services and indicates that she or he understands that termination must be the result of supplying that information; • the Member has been admitted to an institution where she or he is ineligible under the PH-MCO for further services; • the Member’s whereabouts are unknown and the post office returns mail directed to him or her indicating no forwarding address; • the PH-MCO established the fact that the Member has been accepted for MA by another State; or • a change in the level of medical care is prescribed by the Member’s physician.

Time Frames for Notice of Decisions. a. The PHCHIP-MCO is required to must process each request for Prior Authorization (prospective utilization review) of a service and ensure that notify the Member is notified Enrollee of the decision as expeditiously as the MemberEnrollee’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 PHCHIP-MCO must mail written notice of the decision to the MemberEnrollee, the MemberEnrollee’s PCP, and the prescribing Provider within two (2) Business Days after the decision is made. Notification The CHIP- MCO may make notification of coverage approvals may also be made via electronic notices as permitted under 28 Pa. Code 9.753(b). If additional information is needed to make a decision, the PHCHIP-MCO must request such information from the appropriate Provider within forty-forty- eight (48) hours of receiving the request and allow fourteen (14) days for the Provider to submit the additional information. If the PHCHIP-MCO requests additional information, the PHCHIP-MCO must notify the Member Enrollee on the date the additional information is requested, using the template supplied by the Department in Exhibit template, N(7), ) Request for Additional Information Letter. b. Letter available in Docushare. If the requested information is provided within fourteen (14) days, the PHCHIP-MCO must make the decision to approve or deny the service, and notify the Member Enrollee orally, within two (2) Business Days of receipt of the additional information. The PH- CHIP-MCO must mail written notice of the decision to the MemberEnrollee, the MemberEnrollee’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 CHIP-MCO must make the decision to approve or deny the service must be made based upon the available information and notify the Member notified Enrollee orally within two (2) Business Days after the additional information was to have been received. The PHCHIP-MCO must mail written notice of the decision to the MemberEnrollee, the MemberEnrollee’s PCP, and the prescribing Provider within two (2) Business Days after the decision is made. d. . In all cases, the CHIP-MCO must make the decision to approve or deny a covered service or item must be made and the Member Enrollee must receive written notification of the decision no later than twenty-one (21) days from the date the PHCHIP-MCO received the request, or the service or item is automatically approved. To satisfy the twenty-twenty- one

Time Frames for Notice of Decisions. a. ‌ The PH-MCO is required to must process each request for Prior Authorization (prospective utilization review) of a service and ensure that notify the Member is notified of the decision as expeditiously as the Member’s health condition requires, or at least orally, within as follows: a. Within two (2) Business Days of receiving the request, request unless additional information is neededneeded or for requests for urgent or home health services. 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. Notification The PH-MCO may make notification of coverage approvals may also be made via electronic notices permitted under 28 Pa. Code 9.753(b). notices. b. For a request for home health services, within 48 hours. c. For a request related to services to treat an urgent health care service, within 24 hours. d. If additional information is needed to make a decision, the PH-PH- MCO must request such information from the appropriate Provider within forty-eight (48) hours of receiving the request and allow fourteen (14) days 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 supplied by the Department in Exhibit template, N(7), ) Request for Additional Information LetterLetter available in Docushare. b. i. A PH-MCO may supplement submitted information based on current clinical records or other current medical information for an Enrollee as available, if the supplemental information is also made available to the Enrollee or Health Care Provider as part of the Enrollee's authorization case file upon request. ii. In response to a request for missing clinical information, PH-MCO shall accept supplemental information from a Member of the Health Care Provider’s clinical or administrative staff. iii. If the requested information is provided within fourteen (14) daysDays, the PH-MCO must make 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. iv. If the requested information is not received within fourteen (14) days, the decision to approve or deny the service must be made based upon the available information and the Member notified 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 decision to approve or deny a covered service or item must be made and the Member must receive written notification of the decision no later than twenty-one (21) days from the date the PH-MCO received the request, or the service or item is automatically approved. To satisfy the twenty-onefourteen

Time Frames for Notice of Decisions. a. The PH-MCO is required to must process each request for Prior Authorization (prospective utilization review) of a service and ensure that notify the Member is notified of the decision as expeditiously as the Member’s '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 's PCP, and the prescribing Provider within two (2) Business Days after the decision is made. Notification The PH-MCO may make notification of coverage approvals may also be made 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 supplied by the Department in Exhibit template, N(7), ) Request for Additional Information LetterLetter available in Docushare. b. If the requested information is provided within fourteen (14) days, the PH-MCO must make the 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- PH-MCO must mail written notice of the decision to the Member, the Member’s '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 make the decision to approve or deny the service must be made based upon the available information and notify the Member notified 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 '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 must be made and the Member must receive written notification of the decision no later than twenty-one (21) days from the date the PH-MCO received the request, or the service or item is automatically approved. To satisfy the twentytwenty- one (21) day time period, the PH-oneMCO may mail written notice to the Member, the Member's PCP, and the prescribing Provider on or before the eighteenth (18th) day from the date the request is received. If the notice is not mailed by the eighteenth (18th) day after the request is received, the PH-MCO must hand deliver the notice to the Member, or the request is automatically approved. e. If the Member is currently receiving a requested service and the PH-MCO decides to deny the Prior Authorization request, the PH- MCO must mail the written notice of denial at least (10) days prior to the effective date of the denial of authorization for continued services. If probable Member fraud has been verified, the period of advance notice is shortened to five (5) days. The PH-MCO is not required to provide advance notice when it has factual information on the following: • confirmation of the death of a Member; • receipt of a clear written statement signed by a Member that she or he no longer wishes services or gives information that requires termination or reduction of services and indicates that she or he understands that termination must be the result of supplying that information; • the Member has been admitted to an institution where she or he is ineligible under the PH-MCO for further services; • the Member's whereabouts are unknown and the post office returns mail directed to him or her indicating no forwarding address; • the PH-MCO established the fact that the Member has been accepted for MA by another State; or • a change in the level of medical care is prescribed by the Member's physician.

Time Frames for Notice of Decisions. ‌ a. The PH-MCO is required to must process each request for Prior Authorization (prospective utilization review) of a service and ensure that notify the Member is notified 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. Notification The PH-MCO may make notification of coverage approvals may also be made 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 supplied by the Department in Exhibit template, N(7), ) Request for Additional Information LetterLetter available in Docushare. b. If the requested information is provided within fourteen (14) days, the PH-MCO must make the 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- 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 make the decision to approve or deny the service must be made based upon the available information and notify the Member notified 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 must be made and the Member must receive written notification of the decision no later than twenty-one (21) days from the date the PH-MCO received the request, or the service or item is automatically approved. To satisfy the twentytwenty- one (21) day time period, the PH-oneMCO may mail written notice to the Member, the Member’s PCP, and the prescribing Provider on or before the eighteenth (18th) day from the date the request is received. If the notice is not mailed by the eighteenth (18th) day after the request is received, the PH-MCO must hand deliver the notice to the Member, or the request is automatically approved. e. If the Member is currently receiving a requested service and the PH-MCO decides to deny the Prior Authorization request, the PH- MCO must mail the written notice of denial at least (10) days prior to the effective date of the denial of authorization for continued services. If probable Member fraud has been verified, the period of advance notice is shortened to five (5) days. The PH-MCO is not required to provide advance notice when it has factual information on the following: • confirmation of the death of a Member; • receipt of a clear written statement signed by a Member that she or he no longer wishes services or gives information that requires termination or reduction of services and indicates that she or he understands that termination must be the result of supplying that information; • the Member has been admitted to an institution where she or he is ineligible under the PH-MCO for further services; • the Member’s whereabouts are unknown and the post office returns mail directed to him or her indicating no forwarding address; • the PH-MCO established the fact that the Member has been accepted for MA by another State; or • a change in the level of medical care is prescribed by the Member’s physician.

Time Frames for Notice of Decisions. a. The PH-MCO is required to must process each request for Prior Authorization (prospective utilization review) of a service and ensure that notify the Member is notified 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. Notification The PH-MCO may make notification of coverage approvals may also be made 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 supplied by the Department in Exhibit template, N(7), ) Request for Additional Information LetterLetter available in Docushare. b. If the requested information is provided within fourteen (14) days, the PH-MCO must make 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 must be made based upon the available information and notify the Member notified 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 must be made and the Member must receive written notification of the decision no later than twenty-one (21) days from the date the PH-MCO received the request, or the service or item is automatically approved. To satisfy the twentytwenty- one (21) day time period, the PH-oneMCO may mail written notice to the Member, the Member’s PCP, and the prescribing Provider on or before the eighteenth (18th) day from the date the request is received. If the notice is not mailed by the eighteenth (18th) day after the request is received, the PH-MCO must hand deliver the notice to the Member, or the request is automatically approved. e. If the Member is currently receiving a requested service and the PH-MCO decides to deny the Prior Authorization request, the PH- MCO must mail the written notice of denial at least (10) days prior to the effective date of the denial of authorization for continued

Time Frames for Notice of Decisions. a. The PHCHC-MCO is required to must process each request for Prior Authorization (prospective utilization review) of a service and ensure that notify the Member is notified Participant of the decision as expeditiously as the MemberParticipant’s health condition requires, or at least orally, within two (2) Business Days business days of receiving the request, unless additional information is needed. If no additional information is needed, the PHCHC-MCO must mail written notice of the decision to the MemberParticipant, the MemberParticipant’s PCP, and the prescribing Provider within two Business Days (2) business days after the decision is made. Notification The CHC- MCO may make notification of coverage approvals may also be made 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 and signed by the Participant, 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 PHCHC-MCO must request such information from the appropriate Provider within forty-eight two (482) hours business days of receiving the request and allow fourteen (14) days for the Provider to submit the additional information. If the PHCHC-MCO requests additional information, the PHCHC-MCO must notify the Member Participant on the date the additional information is requested, using the template supplied provided by the Department in Exhibit N(7)Department, Request for Additional Information Letter. Timeframes specific to home/vehicle modifications, pest eradication, or assistive technology decisions are addressed in Section V.B.3. b. If the requested information is provided within fourteen (14) days, the PH-CHC- MCO must make the decision to approve or deny the service, and notify the Member Participant orally, within two (2) Business Days business days of receipt of the additional information. The PH- CHC-MCO must mail written notice of the decision to the MemberParticipant, the MemberParticipant’s PCP, and the prescribing Provider within two (2) Business Days business days after the decision is made. c. If the requested information is not received within fourteen (14) days, the CHC-MCO must make the decision to approve or deny the service must be made based upon the available information and notify the Member notified Participant 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 decision to approve or deny a covered service or item must be made and the Member must receive written notification of the decision no later than twenty-one (21) days from the date the PH-MCO received the request, or the service or item is automatically approved. To satisfy the twenty-onetwo

Time Frames for Notice of Decisions. ‌ a. The PH-MCO is required to must process each request for Prior Authorization (prospective utilization review) of a service and ensure that notify the Member is notified 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. Notification The PH-MCO may make notification of coverage approvals may also be made 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 supplied by the Department in Exhibit template, N(7), ) Request for Additional Information LetterLetter available in Docushare. b. If the requested information is provided within fourteen (14) days, the PH-MCO must make 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 must be made based upon the available information and notify the Member notified 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 must be made and the Member must receive written notification of the decision no later than twenty-one (21) days from the date the PH-MCO received the request, or the service or item is automatically approved. To satisfy the twentytwenty- one (21) day time period, the PH-oneMCO may mail written notice to the Member, the Member’s PCP, and the prescribing Provider on or before the eighteenth (18th) day from the date the request is received. If the notice is not mailed by the eighteenth (18th) day after the request is received, the PH-MCO must hand deliver the notice to the Member, or the request is automatically approved. e. If the Member is currently receiving a requested service and the PH-MCO decides to deny the Prior Authorization request, the PH- MCO must mail the written notice of denial at least (10) days prior to the effective date of the denial of authorization for continued

Time Frames for Notice of Decisions. a. The PHCHC-MCO is required to must process each request for Prior Authorization (prospective utilization review) of a service and ensure that notify the Member is notified Participant of the decision as expeditiously as the MemberParticipant’s health condition requires, or at least orally, within two (2) Business Days business days of receiving the request, unless additional information is needed. If no additional information is needed, the PHCHC-MCO must mail written notice of the decision to the MemberParticipant, the MemberParticipant’s PCP, and the prescribing Provider within two Business Days (2) business days after the decision is made. Notification The CHC-MCO may make notification of coverage approvals may also be made via electronic notices as permitted under 28 Pa. PA Code §9.753(b). If additional information is needed to make a decision, the PHCHC-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 PHCHC-MCO requests additional information, the PHCHC-MCO must notify the Member Participant on the date the additional information is requested, using the template supplied by the Department in Exhibit template, N(7), ) Request for Additional Information Letter.Letter on the Intranet supporting CHC.‌ b. If the requested information is provided within fourteen (14) days, the PHCHC-MCO must make the decision to approve or deny the service, and notify the Member Participant orally, within two (2) Business Days business days of receipt of the additional information. The PH- CHC-MCO must mail written notice of the decision to the MemberParticipant, the Memberthe‌ Participant’s PCP, and the prescribing Provider within two (2) Business Days business days after the decision is made. c. If the requested information is not received within fourteen (14) days, the CHC-MCO must make the decision to approve or deny the service must be made based upon the available information and notify the Member notified Participant orally within two (2) Business Days business days after the additional information was to have been received. The PHCHC-MCO must mail written notice of the decision to the MemberParticipant, the MemberParticipant’s PCP, and the prescribing Provider within two (2) Business Days business days after the decision is made.made.‌ d. In all cases, the CHC-MCO must make the decision to approve or deny a covered service or item must be made and the Member Participant must receive written notification of the decision no later than twenty-twenty- one (21) days from the date the PHCHC-MCO received the request, or the service or item is automatically approved. To satisfy the twentytwenty- one (21) day time period, the CHC-oneMCO may mail written notice to the Participant, the Participant’s PCP, and the prescribing Provider on or before the eighteenth (18th) day from the date the request is received. If the notice is not mailed by the eighteenth (18th) day after the request is received, the CHC-MCO must hand deliver the notice to the Participant, or the request is automatically approved.‌ e. If the Participant is currently receiving a requested service and the CHC-MCO decides to deny the Prior Authorization request, the CHC-MCO must mail the written notice of denial at least (10) days prior to the effective date of the denial of authorization for continued services. If probable Participant fraud has been verified, the period of advance notice is shortened to five (5) days. The CHC-MCO is not required to provide advance notice when it has factual information on the following:‌‌  confirmation of the death of a Participant.‌  receipt of a clear written statement signed by a Participant that she or he no longer wishes services or gives information that requires termination or reduction of services and indicates that she or he understands that termination must be the result of supplying that information.  the Participant has been admitted to an institution where she or he is ineligible under the CHC-MCO for further services.  the Participant’s whereabouts are unknown and the post office returns mail directed to him or her indicating no forwarding address.  the CHC-MCO established the fact that the Participant has been accepted for Medical Assistance by another State.  a change in the level of medical care is prescribed by the Participant’s physician.‌

Time Frames for Notice of Decisions. a. The PH-MCO is required to must process each request for Prior Authorization (prospective utilization review) of a service and ensure that notify the Member is notified 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. Notification The PH-MCO may make notification of coverage approvals may also be made 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 supplied by the Department in Exhibit template, N(7), ) Request for Additional Information LetterLetter on the HealthChoices Intranet site. b. If the requested information is provided within fourteen (14) days, the PH-MCO must make the 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 make the decision to approve or deny the service must be made based upon the available information and notify the Member notified 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 must be made and the Member must receive written notification of the decision no later than twenty-one (21) days from the date the PH-MCO received the request, or the service or item is automatically approved. To satisfy the twentytwenty- one (21) day time period, the PH-oneMCO may mail written notice to the Member, the Member’s PCP, and the prescribing Provider on or before the eighteenth (18th) day from the date the request is received. If the notice is not mailed by the eighteenth (18th) day after the request is received, the PH-MCO must hand deliver the notice to the Member, or the request is automatically approved. e. If the Member is currently receiving a requested service and the PH-MCO decides to deny the Prior Authorization request, the PH-MCO must mail the written notice of denial at least (10) days prior to the effective date of the denial of authorization for continued services. If probable Member fraud has been verified, the period of advance notice is shortened to five (5) days. The PH-MCO is not required to provide advance notice when it has factual information on the following: • confirmation of the death of a Member; • receipt of a clear written statement signed by a Member that she or he no longer wishes services or gives information that requires termination or reduction of services and indicates that she or he understands that termination must be the result of supplying that information; • the Member has been admitted to an institution where she or he is ineligible under the PH-MCO for further services; • the Member’s whereabouts are unknown and the post office returns mail directed to him or her indicating no forwarding address; • the PH-MCO established the fact that the Member has been accepted for MA by another State; or • a change in the level of medical care is prescribed by the Member’s physician.

Time Frames for Notice of Decisions. ‌ a. The PH-MCO is required to must process each request for Prior Authorization (prospective utilization review) of a service and ensure that notify the Member is notified 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. Notification The PH-MCO may make notification of coverage approvals may also be made 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 supplied by the Department in Exhibit template, N(7), ) Request for Additional Information LetterLetter available in Docushare. b. If the requested information is provided within fourteen (14) days, the PH-MCO must make the 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- 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 make the decision to approve or deny the service must be made based upon the available information and notify the Member notified 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 must be made and the Member must receive written notification of the decision no later than twenty-one (21) days from the date the PH-MCO received the request, or the service or item is automatically approved. To satisfy the twentytwenty- one (21) day time period, the PH-oneMCO may mail written notice to the Member, the Member’s PCP, and the prescribing Provider on or before the eighteenth (18th) day from the date the request is received. If the notice is not mailed by the eighteenth (18th) day after the request is received, the PH-MCO must hand deliver the notice to the Member, or the request is automatically approved. e. If the Member is currently receiving a requested service and the PH-MCO decides to deny the Prior Authorization request, the PH­ MCO must mail the written notice of denial at least (10) days prior to the effective date of the denial of authorization for continued services. If probable Member fraud has been verified, the period of advance notice is shortened to five (5) days. The PH-MCO is not required to provide advance notice when it has factual information on the following: • confirmation of the death of a Member; • receipt of a clear written statement signed by a Member that she or he no longer wishes services or gives information that requires termination or reduction of services and indicates that she or he understands that termination must be the result of supplying that information; • the Member has been admitted to an institution where she or he is ineligible under the PH-MCO for further services; • the Member’s whereabouts are unknown and the post office returns mail directed to him or her indicating no forwarding address; • the PH-MCO established the fact that the Member has been accepted for MA by another State; or • a change in the level of medical care is prescribed by the Member’s physician.