Timeframes for Medical Authorization Clause Samples
The 'Timeframes for Medical Authorization' clause establishes specific deadlines within which parties must provide or obtain authorization for medical procedures or information. Typically, this clause outlines the number of days allowed for responding to requests for medical records or for granting approval for necessary treatments, ensuring that all parties are aware of their obligations and the timing involved. By setting clear time limits, the clause helps prevent unnecessary delays in medical care or the processing of claims, thereby promoting efficiency and reducing disputes related to timing.
Timeframes for Medical Authorization. A. Emergency Care: No Prior Authorization required, following the reasonable person standard to determine that the presenting complaint might be an emergency.
B. Post-stabilization: Response to request within 30 minutes or the service is deemed approved in accordance with Title 22 CCR Section 53855 (a), or any future amendments thereto.
C. Non-urgent care following an exam in the emergency room: Response to request within 30 minutes or deemed approved.
▇. ▇▇▇▇▇▇▇▇▇▇ review of authorization for treatment regimen already in place: Within five (5) working days or less, consistent with urgency of the Member’s medical condition and in accordance with Health and Safety Code Section 1367.01(h)(3), or any future amendments thereto.
Timeframes for Medical Authorization. A. Emergency Care: No prior authorization required, following the reasonable person standard to determine that the presenting complaint might be an emergency.
B. Post-stabilization: Response to request within 30 minutes or the service is deemed approved in accordance with Title 22 CCR Section 53855 (a), or any future amendments thereto.
C. Non-urgent care following an exam in the emergency room: Response to request within 30 minutes or deemed approved.
▇. ▇▇▇▇▇▇▇▇▇▇ review of authorization for treatment regimen already in place: Within five (5) working days or less, consistent with urgency of the Member’s medical condition and in accordance with Health and Safety Code Section 1367.01, or any future amendments thereto.
E. Retrospective review: Within 30 calendar days in accordance with Health and Safety Code Section 1367.01, or any future amendments thereto.
F. Pharmaceuticals: 24 hours or one (1) business day on all drugs that require prior authorization in accordance with Welfare and Institutions Code, Section 14185 or any future amendments thereto.
▇. ▇▇▇▇▇▇▇ authorizations: Five (5) working days from receipt of the information reasonably necessary to render a decision (these are requests for specialty service, cost control purposes, out-of-network not otherwise exempt from prior authorization) in accordance with Health and Safety Code, Section 1367.01, or any future amendments thereto, but, no longer than 14 calendar days from the receipt of the request. The decision may be deferred and the time limit extended an additional 14 calendar days only where the Member or the Member’s provider requests an extension, or the Contractor can provide justification upon request by the State for the need for additional information and how it is in the Member’s interest. Any decision delayed beyond the time limits is considered a denial and must be immediately processed as such.
Timeframes for Medical Authorization. A. Emergency Care: No Prior Authorization required, following the reasonable person standard to determine that the presenting complaint might be an emergency.
B. Post-stabilization: Upon receipt of an authorization request from an emergency services provider, Contractor shall render a decision within 30 minutes or the request is deemed approved, pursuant to Title 28 CCR Section 1300.71.4.
C. Non-urgent care following an exam in the emergency room: Response to request within 30 minutes or deemed approved.
▇. ▇▇▇▇▇▇▇▇▇▇ review of authorization for treatment regimen already in place: Within 24 hours of the decision, consistent with urgency of the Member’s medical condition and in accordance with Health and Safety Code Section 1367.01 (h)(3).
E. Retrospective review: Within 30 calendar days in accordance with Health and Safety Code Section 1367.01(h)(1)
Timeframes for Medical Authorization. A. Emergency Care: No Prior Authorization required, following the reasonable person standard to determine that the presenting complaint might be an emergency.
B. Post-stabilization: Response to request within 30 minutes or the service is deemed approved in accordance with 22 CCR section 53855 (a).
C. Non-urgent care following an exam in the emergency room: Response to request within 30 minutes or deemed approved.
D. Concurrent review of authorization for treatment regimen already in place: Within five (5) Working Days or less, consistent with urgency of the Member’s medical condition and in accordance with Health and Safety Code section 1367.01(h)(3).
E. Retrospective review: Within 30 calendar days in accordance with Health and Safety Code section 1367.01(h)(1).
F. Routine authorizations: As expeditiously as the Member’s condition requires but within five (5) Working Days from receipt of the information reasonably necessary to render a decision (these are requests for specialty service, cost control purposes, out-of-Network not otherwise exempt from Prior Authorization) in accordance with Health and Safety Code section 1367.01, but, no longer than 14 calendar days from the receipt of the request. The decision may be deferred and the time limit extended an additional 14 calendar days only where the Member or the Member’s Provider requests an extension, or Contractor can provide justification upon request by the State for the need for additional information and how it is in the Member’s interest. Any decision delayed beyond the time limits is considered a denial and must be immediately processed as such.
Timeframes for Medical Authorization