(A)
Whenever an MCO, Accountable Care Partnership Plan, SCO, ICO, or the behavioral
health contractor reaches a decision that constitutes an appealable action, as
described in
130 CMR
610.032(B), it must send a
notice to the member within the following time frames that describes its
decision and its internal appeal procedures:
(1) for a standard service authorization
decision to deny or provide limited authorization for a requested service, no
later than 14 days following receipt of the request for service, unless the
time frame is extended up to 14 additional days because the member or a
provider requested the extension or the MCO, Accountable Care Partnership Plan,
SCO, and ICO, or behavioral health contractor can demonstrate a need for
additional information and how the extension is in the member's
interest;
(2) for an expedited
service decision to deny or provide limited authorization for a requested
service, where a provider requests, or an MCO, Accountable Care Partnership
Plan, SCO, ICO, or behavioral health contractor determines, that following the
standard time frame in 130 CMR 508.011(A) could seriously jeopardize the
member's life or health or ability to attain, maintain, or regain maximum
function, no later than three business days after receipt of the request for
service, unless the time frame is extended up to 14 additional calendar days
because the member requested the extension or the MCO, Accountable Care
Partnership Plan, SCO, ICO, or behavioral health contractor can demonstrate a
need for additional information and how the extension is in the member's
interest;
(3) for termination,
suspension, or reduction of a previous authorization for a service, at least
ten days before the action, except as provided in
42 CFR
431.213; and
(4) for denial of payment where coverage of
the requested service is at issue, on the day of the payment denial, except
that no notice is necessary for procedural denials, which include, but are not
limited to, the following:
(a) failure to
follow the MCO, Accountable Care Partnership Plan, SCO, ICO, or behavioral
health contractor's prior authorization procedures;
(b) failure to follow referral rules;
and
(c) failure to file a timely
claim.
(B)
Whenever an MCO, Accountable Care Partnership Plan, SCO, ICO, or the behavioral
health contractor fails to reach a decision on a standard or expedited service
authorization within the time frames described in 130 CMR 508.011(A)(1) and
(2), whichever is applicable, it must send a notice to the member on the date
that such time frame expires.
