Utilization Review Determination Time Frames
This document defines time frames and notification requirements for utilization review (prospective non-urgent, prospective urgent, and concurrent urgent) and who is affected (providers and members, including fully insured plan specifics).
Administrative edits were made (publication history notes administrative edits).
Utilization Review Timeframes and Criteria
Prospective (Pre-Service) Review of Non-Urgent Services
Timeframe and notice criteria for prospective (pre-service) review of non-urgent services.
ALL of the following
- Decision timeframe: Decision within 2 business days of receipt of the necessary information but not later than 15 business days from receipt of the request.
- Provider verbal notice: Verbal notice must be given to the provider within 24 hours of the authorization or denial determination.
- Written notice (fully insured products): Written notice must be sent to the provider and member within 1 business day of the verbal notice but no later than 15 business days from receipt of the request.
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