Find out what rights you and your patients have under current federal statutes and regulations, such as the Employee Retirement Income Security Act and the Medicare Advantage program.
Requirements relating to basic benefits
Requirements for Certification; Utilization of Nationally Recognized Accreditation Standards; Website Identifying Nationally Recognized Accreditation Entities
Definitions; Clinical Decisions; Carrier’s Medical Necessity Guidelines; Time Limits for Resolution of Non-expedited Internal Grievances; Review of Internal Grievances; Expedited Internal Review of Adverse Determinations; Additional Requirements for Expedited Internal Review; Failure of Carrier to Meet Time Limits
Definitions; Documented prior authorization program, requirements; Timeframes for determinations, concurrent review, retrospective review, adverse determination; Documentation; Utilization review, determinations, appeals; Prior authorization, denial of claims; Reviews for fraud, waste or abuse
Short title; Part definitions; Requirements for initial adverse determinations; Appeals of an electronic and non-electronic initial adverse determination; Prior authorization submissions; Chronic conditions; Clinical criteria; Electronic prior authorization; Expiration date for a prior authorization; Prior authorization and opioid use disorder; Medical necessity; Changing prior authorization requirements; Payment; Prior authorization transfers; Related service; Reviewer criteria; Statistics; Prior authorization requirements; Website notice requirements; Applicability; Provider notification to health carrier; Rules.
Definitions; Operational standards; Medical policies and clinical review criteria; Prior authorization review