Timing of Notice of Action Sample Clauses
Timing of Notice of Action. The IHCP must mail or hand -deliver the notice of action required in Article X.D.1. within the following timeframes:
a. Service Authorization Decisions in Response to a Request for Service
i. For standard service authorization decisions that deny or limit a requested service included in the benefit package, the IHCP must mail or hand deliver notice of action within fourteen (14) calendar days of the request unless the IHCP extends the timeframe for up to fourteen (14) additional calendar days in order to gather more information. If the timeframe is extended, the IHCP must mail or hand deliver a written notification to the member no later than the fourteenth day after the original request. The notification of extension must inform the member that:
a) The member may file a grievance if dissatisfied with the extension, in which case the extension will be considered a denial, and
b) The member may contact the MCO’s Member Rights Specialist for assistance. If the decision is to deny or limit the requested service, the maximum time between a request and notice is twenty-eight (28) calendar days.
ii. A member or provider may request an expedited service authorization decision. For cases in which an expedited decision is needed because a provider indicates, or the IHCP determines, that following the standard timeframe could seriously jeopardize the member's life or health or ability to attain, maintain, or regain maximum function, the IHCP must make the service authorization decision and mail or hand deliver notice as expeditiously as the member’s health condition requires and no later than seventy-two (72) hours after the request unless the timeframe has been extended.
iii. In the case of an expedited decision, the timeline for a decision may be extended by an additional eleven (11) calendar days up to a total of fourteen (14) calendar days.
iv. If the timeframe is extended, the IHCP must:
a) Mail or hand deliver to the member written notice of the reason for the decision to extend the timeframe and the member’s right to file a grievance if he/she disagrees with that decision; and
b) Issue and carry out its determination as expeditiously as the member's health condition requires and no later than the date the extension expires.
v. A standard or expedited service authorization decision that is not reached within the timeframes specified in paragraphs i. or ii. constitutes a denial. In such situations, the IHCP must send a notice of action as soon as the timeframes...
Timing of Notice of Action. The Health Plan shall mail the notice within the following timeframes:
a) For termination, suspension, or reduction of previously authorized Covered Services, at least 10 days before the date of action. In the event of verified probable recipient fraud, the period of advance notice is shortened to 5 days. Notice shall be given by the date of the action for the following, pursuant to in 42 CFR § 431.211, § 431.213, and § 431.214:
(1) The death of an Enrollee
(2) A signed Enrollee statement requesting service termination or providing information that requires the termination or reduction of services
(3) The Enrollee’s address is unknown and mail directed to the Enrollee has no forwarding address
(4) The Enrollee has been accepted for Medicaid services by another local jurisdiction
(5) The Enrollee’s physician prescribes a change in level of medical care
(6) The safety or health of the Enrollee would be endangered, the Enrollee’s health improves sufficiently to allow a more immediate transfer or discharge, or an immediate transfer is required by the Enrollee’s urgent medical needs.
b) For denial of payment, at the time of any action affecting the claim.
c) For standard service authorization decisions that deny or limit services, within the timeframe specified in 42 CFR § 438.210(d)(1).
d) If the Health Plan extends the timeframe in accordance with 42 CFR § 438.210(d)(1), it shall:
(1) Give the Enrollee written notice of the reason for the decision to extend the timeframe and inform the Enrollee of the right to file a Grievance if he or she disagrees with that decision; and
(2) Issue and carry out its determination as expeditiously as the Enrollee's health condition requires and no later than the date the extension expires.
e) For service authorization decisions not reached within the timeframes specified in 42 CFR § 438.210(d) (which constitutes a denial and is thus an adverse action), on the date that the timeframes expire.
f) For expedited service authorization decisions, within the timeframes specified in 42 CFR § 438.210(d).
Timing of Notice of Action. If we decide to deny or limit services you requested or decide not to pay for all or part of a covered service, we will send you a notice when we make our decision. If we are proposing to restrict, reduce, suspend or terminate a service that is authorized, our letter will be sent at least 10 days before we intend to change the service. Any notice we send to you about an action will: Explain the action we have taken or intended to take; Cite the reasons for the action, including the clinical rationale, if any; Describe your right to file an appeal, including whether you have a right to the State’s external appeal process; Describe how to file an internal appeal and the circumstances under which you can request that we speed up (expedite) our review of your internal appeal; Describe the availability of the clinical review criteria relied upon in making the decision, if the action involved issues of medical necessity or whether the treatment or service in question was experimental or investigational; Describe the information, if any, which must be provided by you and/or your provider in order for us to render a decision on appeal. The notice will also tell you about your right to a State Fair Hearing: It will explain the difference between an appeal and a Fair Hearing; It will say that that you do not have to file an appeal before asking for a Fair Hearing; It will explain how to ask for a Fair Hearing; and If we are reducing, suspending, or terminating an authorized service, and you want your services to continue while your appeal is decided, you must ask for a Fair Hearing within 10 days of the date on the notice or the intended effected date of the proposed action, whichever is later.