Section 85.37 - Time limits within which determinations shall be made

PRIOR APPROVAL FOR CARE AND SERVICES

85.37 Time limits within which determinations shall be made. (a) All decisions on requests for prior approval must be made and all required notices shall be sent by the New York State Department of Health to the requesting provider and, where required, to the medical assistance patient-recipient, within 21 calendar days of receipt of such requests by the New York State Department of Health; except that in cases where prior approval requests for dental care are received in area offices outside the five boroughs of New York City and a clinic examination is necessary, the required notices above shall be transmitted within 30 calendar days of receipt of such requests by the respective upstate area office.

(b) In the event prior approval requests must be returned to the requesting provider for submission of additional information, the calendar day limit in subdivision (a) of this section will be tolled from the day the request is returned to the provider until the day the request plus additional information is returned to the New York State Department of Health.

(c) In the event the prior approval request and the requested additional information from the provider is received on a Thursday or Friday which occurs after the 19th calendar day referenced in subdivision (b) of this section, two additional working days may be added to the 21-calendar day limit specified in subdivision (a) of this section.

(d) If a determination is not made and transmitted in accordance with provisions in subdivisions (a)-(c) of this section, the New York State Department of Health shall, within two working days from the expiration of the time limits set forth in subdivisions (a)-(c) of this section, notify the requesting provider and patient-recipient of such fact and of the patient's-recipient's right to request a fair hearing to determine whether the prior approval request should be approved.
 

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