Expediting certain organization determinations
See bold sections below:
Request for expedited determination. An enrollee or a physician (regardless of whether the physician is affiliated with the MA organization) may request that an MA organization expedite an organization determination involving the issues described in § 422.566(b)(3) and (b)(4). (This does not include requests for payment of services already furnished.)
(b) How to make a request.
(1) To ask for an expedited determination, an enrollee or a physician must submit an oral or written request directly to the MA organization or, if applicable, to the entity responsible for making the determination, as directed by the MA organization.
(2) A physician may provide oral or written support for a request for an expedited determination.
(c) How the MA organization must process requests. The MA organization must establish and maintain the following procedures for processing requests for expedited determinations:
(1) Establish an efficient and convenient means for individuals to submit oral or written requests. The MA organization must document all oral requests in writing and maintain the documentation in the case file.
(2) Promptly decide whether to expedite a determination, based on the following requirements:
(i) For a request made by an enrollee the MA organization must provide an expedited determination if it determines that applying the standard timeframe for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.
(ii) For a request made or supported by a physician, the MA organization must provide an expedited determination if the physician indicates that applying the standard timeframe for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.
Medicare Advantage-Medical Necessity Decisions-Deadlines
(d) Actions following denial. If an MA organization denies a request for expedited determination, it must take the following actions:
(1) Automatically transfer a request to the standard timeframe and make the determination within the 72-hour or 14-day timeframe, as applicable, established in § 422.568 for a standard determination. The timeframe begins when the MA organization receives the request for expedited determination.
(2) Give the enrollee prompt oral notice of the denial and subsequently deliver, within 3 calendar days, a written letter that –
(i) Explains that the MA organization will process the request using the 14-day timeframe for standard determinations;
(ii) Informs the enrollee of the right to file an expedited grievance if he or she disagrees with the MA organization’s decision not to expedite; and
(iii) Informs the enrollee of the right to resubmit a request for an expedited determination with any physician’s support; and
(iv) Provides instructions about the grievance process and its timeframes.
(e) Action on accepted request for expedited determination. If an MA organization grants a request for expedited determination, it must make the determination and give notice in accordance with § 422.572.
(f) Prohibition of punitive action. An MA organization may not take or threaten to take any punitive action against a physician acting on behalf or in support of an enrollee in requesting an expedited determination.
(g) Dismissing a request. The MA organization dismisses an expedited organization request in accordance with § 422.568.
[63 FR 35107, June 26, 1998, as amended at 65 FR 40329, June 29, 2000; 70 FR 4739, Jan. 28, 2005; 84 FR 23880, May 23, 2019; 86 FR 6101, Jan. 19, 2021]