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Title: Section 69-10.17 - Right to Expedited Review of Denials of Requests for Prior Approval

Effective Date


69-10.17 Right to Expedited Review of Denials of Requests for Prior Approval.

(a) An expedited review will be provided upon an enrollee showing that (1) he or she submitted a written statement from a physician, physician assistant, or nurse practitioner on the practitioner's letterhead or on the letterhead of the supervising or collaborating physician, if applicable, that the enrollee had an emergency need for the medical service(s) or item(s) in issue and the reason the service or item was needed on an expedited basis and (2) the Fund Administrator denied the request for expedited prior approval. Such reviews must be conducted within ten business days from receipt of the request for expedited review and all documentation supporting the request.

(b) The hearing officer shall make a written recommendation to the Commissioner consistent with the recommendation requirements set forth in § 69-10.16 within five business days of the document based review or hearing.

(c) The Commissioner or his or her designee shall issue a written decision consistent with the decision requirements set forth in § 69-10.16 of this Subpart within five business days of receiving the hearing officer's written recommendation.

(d) As set forth in § 69-10.15 of this Subpart, the service or item may be provided to the enrollee in such a situation pending the expedited prior approval determination and any review of the determination; and a claim for the provision of the service or item during the time period while the prior review decision was pending or, in the event of a review, pending issuance of the review determination, 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.


VOLUME A-1a (Title 10)