|
ROBERT L. EHRLICH, JR., Governor Ch. 415
AND THE AUTHORIZED REPRESENTATIVE WITHIN 15 DAYS AFTER THE REQUEST FOR
PREAUTHORIZATION OF HEALTH CARE SERVICES HAS BEEN RECEIVED BY THE
CARRIER, UNLESS;
1. THE MEMBER OR THE AUTHORIZED REPRESENTATIVE
FAILS TO PROVIDE SUFFICIENT INFORMATION TO MAKE THE DECISION; OR
2. THE CARRIER DETERMINES THAT DUE TO
CIRCUMSTANCES BEYOND THE CONTROL OF THE CARRIER, A 15 DAY EXTENSION IS
NECESSARY.
(II) IF THE MEMBER OR THE AUTHORIZED REPRESENTATIVE FAILS
TO PROVIDE SUFFICIENT INFORMATION TO MAKE THE DECISION, THE CARRIER
SHALL:
1. NOTIFY THE MEMBER AND THE AUTHORIZED
REPRESENTATIVE IN WRITING WITHIN 15 DAYS AFTER RECEIPT OF THE REQUEST
FOR SERVICES OF THE SPECIFIC INFORMATION NECESSARY TO MAKE THE DECISION;
2. ALLOW THE MEMBER OR THE AUTHORIZED
REPRESENTATIVE AT LEAST 45 DAYS TO PROVIDE THE SPECIFIC INFORMATION; AND
3. NOTIFY THE MEMBER AND THE AUTHORIZED
REPRESENTATIVE IN WRITING OF THE CARRIER'S DECISION WITHIN THE EARLIER
OF:
A. 15 DAYS AFTER RECEIPT OF THE SPECIFIC INFORMATION
REQUIRED IN ITEM 1 OF THIS SUBPARAGRAPH; OR
B. 15 DAYS AFTER THE DATE THE SPECIFIC INFORMATION
WAS REQUIRED TO BE PROVIDED TO THE CARRIER.
(III) IF THE CARRIER DETERMINES THAT A 15-DAY EXTENSION IS
NECESSARY DUE TO CIRCUMSTANCES BEYOND THE CONTROL OF THE CARRIER, THE
CARRIER SHALL NOTIFY THE MEMBER AND AUTHORIZED REPRESENTATIVE BEFORE
THE EXPIRATION OF THE INITIAL 15-DAY PERIOD OF:
1. THE CIRCUMSTANCES REQUIRING THE EXTENSION OF
TIME; AND
2. THE DATE BY WHICH THE CARRIER EXPECTS TO RENDER
A DECISION.
(5) (I) FOR A RETROSPECTIVE DENIAL OF HEALTH CARE SERVICES,
THE CARRIER SHALL PROVIDE WRITTEN NOTICE TO THE MEMBER AND THE
AUTHORIZED REPRESENTATIVE WITHIN 30 DAYS AFTER THE REQUEST FOR
PAYMENT FOR HEALTH CARE SERVICES IS RECEIVED BY THE CARRIER, SUBJECT TO
SUBPARAGRAPHS (II) AND (III) OF THIS PARAGRAPH.
(II) IF THE MEMBER OR THE AUTHORIZED REPRESENTATIVE FAILS
TO PROVIDE SUFFICIENT INFORMATION TO MAKE THE DECISION ON THE PAYMENT
OF HEALTH CARE SERVICES, THE CARRIER SHALL:
- 1509 -
|
