§36-6570.6. Time frame to make prior authorization or adverse
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determination.
A. If a utilization review entity requires prior authorization of a health care service, the utilization review entity must make a prior authorization or adverse determination and notify the enrollee and the enrollee's health care provider of the prior authorization or adverse determination in accordance with the time frames set forth below:
1. For purposes of approving prior authorization for urgent health care services, within seventy-two
(72)hours of obtaining all necessary information to make the prior authorization or adverse determination; or
2. For purposes of approving prior authorization for non-urgent health care services, within seven
(7)days of obtaining all necessary information to make the prior authorization or adverse determination.
For purposes of this section, "necessary information" includes, but is not limited to, the results of any face-to-face clinical evaluation or second opinion that may be required.
B. For those health care providers that submit all necessary information through the utilization review entity's authorized prior authorization system, health care services are deemed authorized if a utilization review entity fails to comply with the deadlines set forth in this section.
C. In the notification to the health care provider that a prior authorization has been approved, the utilization review entity shall include in such notification the duration of the prior authorization or the date by which the prior authorization will expire. Added by Laws 2024, c. 303, § 7, eff. Jan. 1, 2025.