§1260.44. Timeframes for determinations; concurrent review; retrospective review; adverse determination

            A.(1) A health insurance issuer or utilization review entity shall maintain written procedures for making utilization review determinations and for notifying enrollees and providers acting on behalf of enrollees of its determination and shall make a utilization review determination as expeditiously as the enrollee‘s health condition requires, but in all cases no later than the time periods set forth in this Section.

            (2) For purposes of this Section, “enrollee” includes the authorized representative of an enrollee.

            B.(1) For any request requiring authorization by the requesting provider as being medically necessary for the treatment or management of an urgent condition, a health insurance issuer or utilization review entity shall offer an expedited review by electronic means to the provider requesting prior authorization. When such a request is made by the provider, the health insurance issuer shall electronically communicate its decision to the provider as soon as possible, but not more than two business days from receipt of the request. If additional information is needed and requested for the health insurance issuer or utilization review entity to make its determination, the issuer or entity shall electronically communicate its decision to the provider as soon as possible, but not more than forty-eight hours from receipt of the required additional information.

            (2) For any requests from a provider for healthcare services requiring prior authorization for which the health insurance issuer does not receive a request for expedited review, the health insurance issuer shall communicate its decision on the prior authorization request no more than five business days from the receipt of the request. If additional information is needed and requested for the health insurance issuer to make its determination, the health insurance issuer shall communicate its decision to the provider no more than five business days from receipt of the additional information.

            (3) The health insurance issuer shall provide an initial notification of its determination to the provider rendering the service either by telephone or electronically within twenty-four hours of making the determination.

            C.(1) For concurrent review determinations, a health insurance issuer or utilization review entity shall make the determination within twenty-four hours of obtaining all necessary information from the provider or facility.

            (2) In the case of a determination to certify an extended stay or additional services, the health insurance issuer or utilization review entity shall provide an initial notification of its certification to the provider rendering the service either by telephone or electronically within twenty-four hours of making the concurrent review certification and shall provide written confirmation to the enrollee and the provider within three business days of making the certification. The health insurance issuer shall include in the initial and written notifications the number of extended days or the next review date, the new total number of days or services approved, and the date of admission or initiation of services.

            D. For retrospective review determinations, a health insurance issuer shall make the determination within thirty business days of receiving all necessary information. A health insurance issuer shall provide notice of the determination in writing to the enrollee and provider within three business days of making the retrospective review determination.

            E.(1) In the case of an adverse determination, the health insurance issuer shall provide an initial notification to the provider rendering the service either by telephone or electronically within twenty-four hours of making the adverse determination and shall provide written or electronic notification to the enrollee and the provider within three business days of making the adverse determination.

            (2) A health insurance issuer shall include in its written or electronic notification of an adverse determination all of the reasons for the determination, including the clinical rationale, and the instructions for initiating an appeal or reconsideration of the determination.

            F. For purposes of this Section, “necessary information” includes the results of any face-to-face clinical evaluation or second opinion that may be required. If the request for utilization review from the provider is not accompanied by all necessary information required by the health insurance issuer, the health insurance issuer has one calendar day to inform the provider of the particular additional information necessary to make the determination and shall allow the provider at least two business days to provide the necessary information to the health insurance issuer. In cases where the provider or an enrollee will not release necessary information, the health insurance issuer may deny certification of an admission, procedure, or service.

            G. If a health insurance issuer fails to make a determination within the timeframes set forth in Subsection B of this Section, the health insurance issuer shall not deny a claim based upon a lack of prior authorization.

            Acts 2023, No. 312, §1, eff. Jan. 1, 2024.