Service Review and Authorization Timeframes Sample Clauses

Service Review and Authorization Timeframes. The Contractor shall make Prior Authorization determinations in a timely and consistent manner so that Enrollees with comparable medical needs receive comparable and consistent levels, amounts, and duration of services as supported by the Enrollee’s medical condition, records, and previous affirmative coverage decisions. Unless otherwise specified, the Contractor shall meet, and shall require Subcontractors to meet, the following timelines for conduct of Medical Necessity and service authorization reviews: A. Complete the review process for a standard Prior Authorization request within two (2) Business Days of receiving the request. The timeframe for a standard authorization request may be extended up to fourteen (14) Days if the Provider or Enrollee requests an extension, or if the Contractor justifies, in writing, to the Department a need for additional information and how the extension is in the Enrollee’s best interest. B. For cases in which a Provider indicates, or the Contractor determines, that following the standard timeframe could seriously jeopardize the Enrollee’s life or health or ability to attain, maintain, or regain maximum function, complete an expedited authorization decision within twenty-four (24) hours and provide notice as expeditiously as the Enrollee’s health condition requires; C. A request for authorization or preauthorization for treatment of an Enrollee with a diagnosis of substance use disorder shall be considered an Expedited Authorization Request by the provider and the Contractor; D. Complete post-service (retrospective) review requests within fourteen (14) Days or, if the Enrollee or the Provider requests an extension or the Contractor justifies in writing to the Department a need for additional information and how the extension is in the Enrollee’s interest, may extend up to an additional fourteen (14) Days. E. Upon request of an Enrollee or Provider, provide written confirmation of the Contractor’s decision within three (3) Business Days of providing notification of a decision if the initial decision was not in writing. The written confirmation shall be written in accordance with Enrollee Rights and Responsibilities.