20-3404. Prior authorization requirement timelines

A. If a plan offered by a health care services plan contains a prior authorization requirement, all of the following apply:

1. For prior authorization requests concerning urgent health care services, the health care services plan or its utilization review agent shall notify the provider of the prior authorization or adverse determination not later than five days after the receipt of all necessary information to support the prior authorization request.

2. For prior authorization requests concerning health care services that are not urgent health care services, the health care services plan or its utilization review agent shall notify the provider of the prior authorization or adverse determination not later than fourteen days after receipt of all necessary information to support the prior authorization request.

3. On receipt of information from the provider in support of a prior authorization request, the health care services plan or its utilization review agent shall provide a receipt in the same format that the request was made to the provider acknowledging that the information was received, unless the necessary return contact information is not provided.

B. The notification required under subsection A of this section shall state whether the prior authorization request is approved, denied or incomplete. If the prior authorization request is denied, the health care services plan or its utilization review agent shall state the specific reason for the denial. For a request that is considered incomplete, the provider shall have the opportunity to submit additional information. Once the provider submits additional information on incomplete requests, the health care services plan has five days to review and respond to requests for health care services deemed urgent and fourteen days to review and respond to requests for health care services deemed not urgent.

C. A prior authorization request is deemed granted if a health care services plan or its utilization review agent fails to comply with the deadlines and notification requirements of this section.

D. A prior authorization request, once granted or deemed granted, is binding on the health care services plan, may be relied on by the enrollee and provider and may not be rescinded or modified by a health care services plan or its utilization review agent after the provider renders the authorized health care services in good faith and pursuant to the authorization unless there is evidence of fraud or misrepresentation by the provider.

E. On a denial of a prior authorization request, the enrollee and the provider may exercise the review and appeal rights specified in chapter 15, article 2 of this title.