Currentharvard pilgrim health carePolicy N/A

Utilization Review Determination Time Frames

Governs time frames and notification requirements for utilization review organizational determinations affecting members, including SCO and integrated plans; applies to members, providers, and delegated vendors performing ODs.

Policy Summary

Payerharvard pilgrim health care

PolicyUtilization Review Determination Time Frames

Policy CodePolicy N/A

Change TypeClarified notificationsadministrative updates

Effective DateN/A

Next Review DateJan 1, 2026

Key ActionProviders may request expedited determinations; if a provider makes or supports an expedited request the plan must automatically expedite.

SourceLink

POLICY UPDATE CHANGES

Updated notification time frame information and defined successful verbal notice.

Updated introduction paragraph.

Administrative edit; link updated.

24 hoursexpedited decision timeframe

72 hoursmany urgent/Part B standard

7 daysstandard prospective non-drug

30 daysretrospective review

10 days

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Utilization Review Determination Time Frames & Notifications

UR determination time frames and notifications

Time frames, extension rules, and notification requirements by review type.

Whether to Expedite a Request for a Determination: A decision must be made within 24 hours whether to expedite. Tufts Health Plan must automatically expedite the determination if a provider makes or supports the request. Requests that only involve claims for payment of services already received cannot be expedited.

If an expedited determination request is denied: transfer the request to the standard timeframe; the member must receive prompt oral notice of the denial that includes appeal rights and may submit written notice within 3 calendar days. The notice must explain that the organization will process the request using the 7-day standard timeframe, inform the member of the right to file an expedited grievance and provide instructions, and inform the member of the right to resubmit with physician support so the request will be automatically expedited.

Part B Drug Prospective Expedited (Urgent): Determination and notification must occur within 24 hours of receipt of the request. These timeframes cannot be extended. Notice of denial must also occur within 24 hours.

Non-Drug Prospective Expedited (Urgent): Determination must occur within 72 hours after receipt of the request. The timeframe may be extended up to 14 calendar days only if: the enrollee requests the extension; the extension is justified in the enrollee's interest to obtain additional medical evidence from a non-contracted provider needed for a favorable decision; or extraordinary/exigent/non-routine circumstances justify the extension and it is in the enrollee's interest. If extended, the enrollee must be notified in writing of the reasons and of the right to file an expedited grievance.

Concurrent Expedited (Urgent): Concurrent urgent requests must be completed as soon as possible, considering medical exigencies, but no later than 72 hours of receipt. Verbal notification must occur within 72 hours. For Tufts Medicare Preferred only, written notification must be sent within 72 hours of a successful verbal notice. The time and date of notification, name of staff communicating the determination, and name of person notified must be documented. If verbal notification does not occur, written notification must be sent to the member and requesting provider within 72 hours.

Part B Drug Standard Prospective (Non-urgent): Determination and notification must be completed as expeditiously as the member's health requires, but no later than 72 hours after receipt of request. These timeframes cannot be extended. Verbal and written notification (including notice of denial) must occur within 72 hours.

Non‑Part B Drug Standard Prospective (Non-urgent): Determination and notification must be completed as expeditiously as the member's health requires, but no later than 7 calendar days after receipt of request. The timeframe may be extended up to 14 calendar days in extreme circumstances; if extended, the member must be notified in writing using a CMS-approved template. Document time and date of notification, staff name, and person notified. Written notification must be sent to the member no later than 7 days (or additional 14 days if extended).

Retrospective Review: Determination and notification must be made within 30 calendar days after receipt of the request. An optional written notification may be sent to the provider and member within 60 calendar days of the request (or an additional 15 days if an extension was granted). Notice of denial must be sent in writing to the provider and member within 60 calendar days unless extended.

Review Resulting in Reduction/Suspension/Termination of Previously Authorized Service: If Tufts Health Plan SCO makes such a determination prior to the original authorization end date, written notification must occur at least 10 calendar days prior to the effective date. The notification timeframe may be shortened to 5 calendar days in instances of probable fraud.

Expedited Requests and Post-Acute Prior Authorization

Prior Authorization

Expedited determination requests — provider-supported requests are automatically expedited

Providers may request an expedited determination; if a provider makes or supports an expedited request, the plan must automatically expedite the determination. If Tufts Health Plan denies the request for an expedited determination/organizational determination (OD), it must automatically transfer the request to the standard time frame and provide prompt oral notice of the denial, including the member's appeal rights and ability to deliver written notice within 3 calendar days to explain that the request will be processed under the 7-day standard timeframe and how to file an expedited grievance.

Tufts Health Plan must automatically expedite when a provider makes or supports the request.
If expedited is denied, transfer to standard timeframe and give prompt oral notice including appeal rights; member may provide written notice within 3 calendar days.
Notice must explain transfer to 7-day standard timeframe, right to file an expedited grievance, instructions for the expedited grievance process, and the option to resubmit an expedited request with physician support.

Key Terms

Provider (definition)

DefinitionProvider: a health care professional/practitioner, facility or vendor.

Who is includedMay be individual clinicians, institutional facilities (e.g., hospitals, SNFs), or contracted vendors performing authorizations or utilization review.

Role in ODsProviders may submit requests for determinations, request expedited reviews, and receive notices of authorization or denial.

Successful verbal notice (definition and requirements)

DefinitionSuccessful verbal notice includes either leaving a message on a secure voicemail or speaking directly to the member or the member's legally authorized representative.

Tufts Medicare Preferred requirementIf required for Tufts Medicare Preferred, written notification must be sent within 72 hours of a successful verbal notice.