Section 69-10.15 - Expedited Prior Approval Process

69-10.15 Expedited Prior Approval Process.

(a) An expedited prior approval determination will be made within hours two business days of receiving a prior approval request of a physician on the physician's letterhead that states that the enrollee has an emergency need for a service or item that requires prior approval and the reason that the service or item is needed on an expedited basis and any other supporting documentation provided by the physician.

(b) The service or item may be provided to the enrollee in an emergency situation when there is no one from the Fund Administrator available to approve the request, provided that an expedited approval request is submitted within two business days of the determination of the emergency need. A claim for the provision of the service or item for the period from the time the emergency need was determined to the time of issuance of the review determination, if applicable, can be submitted to the Fund Administrator for payment, provided that there are no delays as the result of an untimely submission of supporting documentation or a request for an extension of time on the part of the enrollee or any person acting on the enrollee's behalf.

Effective Date: 
Wednesday, June 18, 2014
Doc Status: 
Complete