Common use of Time Frames Clause in Contracts

Time Frames. 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. The Division of Medicaid processes Prior Authorization requests for prescription drugs within twenty-four (24) hours of receiving the request. The Contractor shall adhere to this time frame. Prior authorization requirements must include the requirement that a Member may receive a minimum of a three (3) day emergency supply for prior authorized drugs until authorization is completed. The 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 the Contractor requires additional medical information in order to make a decision, the Contractor will notify the requesting Provider of additional medical information needed and the Contractor must allow three (3) calendar days and/or two (2) business for the requesting Provider to submit the medical information. If the Contractor does not receive the additional medical information, the Contractor shall make a second attempt to notify the requestor of the additional medical information needed and the Contractor must allow one (1) business day or three (3) calendar days) for the requestor to submit medical information to the Contractor. Once all information is received from the Provider, if the 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 the Contractor, or if the Contractor justifies 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 the Contractor has received all necessary medical information to render a decision and the Contractor requires additional calendar days to make a decision. The Contractor must provide to the Division the reason(s) justifying the additional calendar days needed to render a decision. The Division will evaluate the Contractor’s extension request and notify the Contractor of decision within three (3) calendar days and/or two (2) business days of receiving the 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 an Expedited Authorization 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, Provider, or the Contractor. 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 the Contractor has received all necessary medical information to render a decision and the Contractor requires additional calendar days to make a decision. The Contractor must provide to the Division the reason(s) justifying the additional calendar days needed to render a decision. The Division will evaluate the Contractor’s extension request and notify the Contractor of decision within three (3) calendar days and/or two (2) business days of receiving the Contractor’s request for extension.

Time Frames. The Contractor must notify the requesting Provider 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 provider and/or Member. The notice must meet the requirements specified in 42 C.F.R. § 438.404. The Division of Medicaid processes Prior Authorization requests for prescription drugs within twenty-four (24) hours of receiving the request. The Contractor shall adhere to this time frame. Prior authorization requirements must include the requirement that a Member may receive a minimum of a three (3) day emergency supply for prior authorized drugs until authorization is completed. The 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 the Contractor requires additional medical information in order to make a decision, the Contractor will notify the requesting Provider provider of additional medical information needed and the Contractor must allow three (3) calendar days and/or two (2) business for the requesting Provider provider to submit the medical information. If the Contractor does not receive the additional medical information, the Contractor shall make a second attempt to notify the requestor of the additional medical information needed and the Contractor must allow one (1) business day or three (3) calendar days) for the requestor to submit medical information to the Contractor. Once all information is received from the Providerprovider, if the 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 provider to the Contractor, or if the Contractor justifies to the Division DOM a need for additional information and how the extension is in the Member’s best interest. The extension request to the Division DOM applies only after the Contractor has received all necessary medical information to render a decision and the Contractor requires additional calendar days to make a decision. The Contractor must provide to the Division DOM the reason(s) justifying the additional calendar days needed to render a decision. The Division DOM will evaluate the Contractor’s extension request and notify the Contractor of decision within three (3) calendar days and/or two (2) business days of receiving the Contractor’s request for extension. The Contractor must expedite authorization for services when the Provider 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 an Expedited Authorization 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, Providerprovider, or the Contractor. The Contractor must justify to the Division DOM a need for additional information and how the extension is in the Member’s best interest. The extension request to the Division DOM applies only after the Contractor has received all necessary medical information to render a decision and the Contractor requires additional calendar days to make a decision. The Contractor must provide to the Division DOM the reason(s) justifying the additional calendar days needed to render a decision. The Division DOM will evaluate the Contractor’s extension request and notify the Contractor of decision within three (3) calendar days and/or two (2) business days of receiving the Contractor’s request for extension.