Section R9-34-215. Contractor Time-frame for an Expedited Appeal Resolution

A.       For expedited resolution of an appeal, a contractor shall resolve the appeal and mail a written Notice of Appeal Resolu­ tion to the enrollee within three working days after the day the contractor receives the appeal. The contractor shall make rea­ sonable efforts to provide prompt oral notice.

B.       If the enrollee requests an extension of the three working day time-frame in subsection (A), the contractor shall extend the time-frame up to an additional 14 days.

C.       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) up to an additional 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

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.

D.       For resolution decisions not reached within the time-frame in this Section, the appeal 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).