Section R9-34-206. Contractor Notice of Action Time-frame for Ser­ vice Authorization Requests

A.       For an authorization decision, not covered under subsection (B), for a service requested on behalf of an enrollee, the con­ tractor shall mail a Notice of Action within 14 calendar days following the receipt of the enrollee's request.

B.       For an authorization request in which the provider indicates or the contractor determines that following the time-frame in sub­ section (A) could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum func­ tion the contractor shall make an expedited authorization decision and mail the Notice of Action as expeditiously as the enrollee's health condition requires, but not later than three working days after receipt of the request for service.

C.       Ifthe enrollee requests an extension of the time-frame in sub­ section (A) or (B), the contractor shall extend the time-frame up to an additional 14 days as requested by the enrollee.

D.       If the contractor needs additional information and the exten­ sion is in the best interest of the enrollee, the contractor shall extend the time-frame in subsection (A) or (B) up to an addi­ tional 14 days. If the contractor extends the time-frame, the contractor shall:

1.       Give the enrollee written notice of the reason for the deci­ sion to extend the time-frame and inform the enrollee of the right to file a grievance if the enrollee disagrees with the decision, and

2.        Issue and carry out the determination as expeditiously as the enrollee's health condition requires and no later than the date the extension expires.

E.       For service authorization decisions not reached within the maximum time-frame in this Section, the authorization shall be considered denied on the date that the time-frame expires.

Historical Note

New Section made by final rulemaking at 10 A.A.R. 828, effective April 3, 2004 (Supp. 04-1).