Sec. 10.67.09.04. MCO Actions and Decisions

A. For certain services to enrollees that require preauthorization the following conditions apply:

(1) For standard authorization decisions, the MCO shall make a determination within 2 business days of receipt of necessary clinical information, but not later than 14 calendar days from the date of the initial request so as not to adversely affect the health of the enrollee;

(2) For expedited authorization decisions, the MCO shall make a determination and provide notice no later than 72 hours after receipt of the request for service if the provider indicates or the MCO determines that the standard time frame stated in §A(1) of this regulation could jeopardize:

(a) The enrollee’s life;

(b) The enrollee’s health; or

(c) The enrollee’s ability to attain, maintain, or regain maximum function;

(3) For all covered outpatient drug authorization decisions, the MCO shall provide notice by telephone or other telecommunication device within 24 hours of a preauthorization request in accordance with section 1927(d)(5)(A) of the Social Security Act;

(4) Standard and expedited authorization decisions may be extended up to 14 calendar days, if the following conditions are met:

(a) The enrollee or the provider requests an extension; or

(b) The MCO justifies to the Department, upon request, a need for additional information and how the extension is in the enrollee’s interest; and

(5) If the MCO successfully justifies extending the standard service authorization decision time frame, the MCO shall:

(a) Give the enrollee written notice of the reason for the decision to extend the time frame;

(b) Inform the enrollee of the right to file a grievance if he or she disagrees with the extension decision; and

(c) Issue and carry out the MCO’s determination as expeditiously as the enrollee’s health condition requires but not later than the date the extension expires.

B. Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested:

(1) Shall be made by a health care professional who has appropriate clinical expertise in treating the enrollee's condition or disease; and

(2) May not be based solely on diagnosis, type of illness, or condition.

C. An MCO shall ensure that compensation to individuals or entities that conduct utilization management activities is not structured to provide incentives for the individual or entity to deny, limit, or discontinue medically necessary services to any enrollee.

D. Notices of a decision to deny a standard authorization shall be provided to the enrollee and the requesting provider within 72 hours from the date of determination.

E. An MCO shall give an enrollee written notice of any action within the following time frames:

(1) At least 10 days before the action for termination, suspension, or reduction of a previously authorized covered service;

(2) The notice period is reduced to 5 days if probable enrollee fraud has been verified;

(3) By the date of the action for the following:

(a) The MCO has factual information confirming the death of an enrollee;

(b) A signed written enrollee statement requesting service termination or giving information requiring termination or reduction of services, where the enrollee understands that this is the result of supplying that information;

(c) The enrollee's admission to an institution where they are ineligible for further services;

(d) The enrollee's address is unknown and mail directed to the enrollee has no forwarding address;

(e) The enrollee has been accepted for Medicaid services by another jurisdiction;

(f) The enrollee's physician prescribes a change in the level of medical care; or

(g) An adverse determination made with regard to the preadmission screening requirements for nursing facility admissions; and

(4) As soon as practicable for nursing facility transfers or discharges when:

(a) The safety or health of individuals in the facility would be endangered;

(b) The enrollee’s health improves sufficiently to allow a more immediate transfer or discharge; or

(c) An immediate transfer or discharge is required by the enrollee’s urgent medical needs; and

(5) For denial of payment, at the time of any action affecting the claim.

F. A notice of adverse action shall:

(1) Be in writing;

(2) Meet the following requirements:

(a) Be translated for enrollees who speak prevalent non-English languages;

(b) Include language clarifying that oral interpretation is available for all languages and how to access it;

(c) Be written in an easily understood language and format that takes into consideration enrollees with special needs;

(d) Be available in alternative formats; and

(e) Inform enrollees that information is available in alternative formats and how to access those formats; and

(3) Contain the following information:

(a) The action the MCO has made or intends to make;

(b) The reasons for the action, including the right for the enrollee to be provided upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the MCO’s action, including:

(i) Medical necessity criteria; and

(ii) Any processes, strategies, or evidentiary standards used in setting coverage limits;

(c) The enrollee’s right to request an appeal of the MCO’s action, including information on:

(i) Exhausting the MCO’s one level of appeal; and

(ii) The right to request a State fair hearing;

(d) The procedures for exercising the rights described;

(e) The circumstances under which an appeal process can be expedited and how to request it;

(f) The enrollee’s right to have benefits continue pending resolution of the appeal;

(g) How to request that benefits be continued; and

(h) The circumstances under which the enrollee may be required to pay the costs of the services.

G. If an MCO does not make an authorization decision within the times specified in §A of this regulation, the untimely decision is considered a denial and thus an adverse action subject to the notice requirements in §§C and E of this regulation.