Timeframes for Authorization Decisions Sample Clauses

Timeframes for Authorization Decisions. The Contractor is required to acknowledge receipt of a standard authorization request for behavioral health inpatient services within two (2) hours and provide a decision within twelve (12) hours of receipt of the request. The Contractor shall provide for the following timeframes for authorization decisions and notices: For denial of payment that may result in payment liability for the Individual, at the time of any Action or Adverse Authorization Determination affecting the claim. For termination, suspension, or reduction of previously authorized Contracted Services, ten (10) calendar days prior to such termination, suspension, or reduction, unless the criteria stated in 42 C.F.R. §§ 431.213 and 431.214 are met. Standard authorizations for planned or elective service determinations: The authorization decisions are to be made and notices of Adverse Authorization Determinations are to be provided as expeditiously as the Individual’s condition requires. The Contractor must make a decision to approve, deny, or request additional information from the provider within five (5) calendar days of the original receipt of the request. If additional information is required and requested, the Contractor must give the provider five (5) calendar days to submit the information and then approve or deny the request within four (4) calendar days of the receipt of the additional information. An extension of up to fourteen (14) additional calendar days (not to exceed twenty-eight (28) calendar days total) is allowed under the following circumstances: The Individual or the provider requests the extension; or The Contractor justifies and documents a need for additional information and how the extension is in the Individual’s interest. If the Contractor extends the timeframe past fourteen (14) calendar days of the receipt of the request for service: The Contractor shall provide the Individual written notice within three (3) Business Days of the Contractor’s decision to extend the timeframe. The notice shall include the reason for the decision to extend the timeframe and inform the Individual of the right to file a Grievance if he or she disagrees with that decision. The Contractor shall issue and carry out its determination as expeditiously as the Individual’s condition requires, and no later than the date the extension expires.