Procedures for expedited utilization review and benefit determinations
See bold text below:
(a) A health care insurer shall establish and maintain written procedures for
(1) receiving a benefit request from a covered person or the covered person’s authorized representative;
(2) making an expedited utilization review and benefit determination with respect to
(A) an urgent care request; and
(B) a concurrent review urgent care request; and
(3) notifying a covered person or the covered person’s authorized representative of the health care insurer’s determination not later than the specified time frames under this section.
(b) The written procedures under (a) of this section must provide that, if a covered person or the covered person’s authorized representative fails to follow the health care insurer’s procedures for filing an urgent care request, the health care insurer shall notify the covered person or the covered person’s authorized representative of the failure and the proper procedures to follow for filing the request. A health care insurer shall provide the notice in this subsection to the covered person or the covered person’s authorized representative as soon as possible, but not later than 24 hours after receipt of the request. A health care insurer may provide the notice orally, unless the covered person or the covered person’s authorized representative requests the notice to be in writing.
(c) The provisions of (b) of this section apply only if the failure is a communication
(1) by a covered person or a covered person’s authorized representative that is received by a person or organizational unit of the health care insurer responsible for handling benefit matters; and
(2) that refers to a specific
(A) covered person;
(B) medical condition or symptom; and
(C) health care service, treatment, or provider for which approval is requested.
State Medical Necessity Decisions-Deadlines
(d) Except under (e) of this section, for an urgent care request, a health care insurer shall notify the covered person or the covered person’s authorized representative of the health care insurer’s determination with respect to the request, whether the determination is an adverse determination or not, as soon as possible taking into account the medical condition of the covered person, but not later than 24 hours after the receipt of the request by the health care insurer. If a health care insurer’s determination is an adverse determination, the health care insurer shall provide notice of the adverse determination under (l) of this section.
(e) For an urgent care request, if a covered person or the covered person’s authorized representative fails to provide sufficient information for a health care insurer to make a determination, the health care insurer shall notify the covered person or the covered person’s authorized representative, orally or, if requested by the covered person or the covered person’s authorized representative, in writing, of the failure and state what specific information is needed. The health care insurer shall provide the notice as soon as possible, but not later than 24 hours after receipt of the request.
(f) A health care insurer shall provide a covered person or the covered person’s authorized representative a reasonable period of time to submit the specified information, taking into account the circumstances, but not less than 48 hours after notifying the covered person or the covered person’s authorized representative of the failure to submit sufficient information under (e) of this section.
State Medical Necessity Decisions-Deadlines
(g) A health care insurer shall notify a covered person or the covered person’s authorized representative of the health care insurer’s determination with respect to the urgent care request as soon as possible, but not later than 48 hours after the earlier of
(1) the health care insurer’s receipt of the requested specified information; or
(2) the end of the period provided for the covered person or the covered person’s authorized representative to submit the requested specified information.
(h) If a covered person or the covered person’s authorized representative fails to submit the information before the end of the period of the extension, as specified in (f) of this section, a health care insurer may deny the certification of the requested benefit.
(i) If a health care insurer’s determination of an urgent care request is an adverse determination, a health care insurer shall provide notice of the adverse determination under (l) of this section.
State Medical Necessity Decisions-Deadlines
(j) For a concurrent review urgent care request involving a request by a covered person or the covered person’s authorized representative to extend the course of treatment beyond the initial period of time or the number of treatments, if the request is made 24 hours before the expiration of the prescribed period of time or number of treatments, a health care insurer shall make a determination, whether the determination is an adverse determination or not, as soon as possible, taking into account the covered person’s medical condition, but not later than 24 hours after the health care insurer’s receipt of the request. If the health care insurer’s determination is an adverse determination, the health care insurer shall provide notice of the adverse determination under (l) of this section.
(k) The time period within which a determination is required to be made under this section begins on the date the request is filed with a health care insurer under the health care insurer’s procedures established under 3 AAC 28.906 for filing a request, without regard to whether all of the information necessary to make the determination accompanies the filing.
(l) The requirements under 3 AAC 28.910(n) – (t) for a standard utilization review and benefit determination apply to an expedited review and benefit determination. An expedited review and benefit determination notification of an adverse determination must include a description of a health care insurer’s expedited review procedures established under 3 AAC 28.938.