New York State Medicaid Managed Care Service Authorization and Appeals Timeframe Comparison

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Revised: February 2, 2018

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Appendix F
Appendix K
Service Authorization Requests
Prior Authorization
Expedited 3 business days* 3 business days* 72 hrs*
Standard 3 business days after all info but not > 14 days* 3 business days after all info but not >14 days* 3 business days after all info but not > 14 days*
Certified Court MH/SUD Services N/A (PHL 4903 standard applies) 72 hrs*
Pharmacy Immediate auth for 72 hour emergency supply Immediate auth for 72 hour emergency supply; 7 day supply for opioid withdrawal/stabili-zation 24 hours; immediate auth for 72 hour emergency supply; immediate access to 5 day supply for SUD treatment medication (from INSL 3216, 3221, and 4303); immediate auth of 7 day supply for opioid withdrawal/ stabilization
Concurrent Review
Expedited 1 business day after all info; no more than 3 business days* 1 but not > 3 business days* 1 business day after all info; no more than 72 hours*
Standard 1 business day after all info; no more than 14 days* 1 business day but not > 14 days* 1 business day after all info; no more than 14 days*
Home care after inpatient stay 1 business day after all info; no more than 3 business days* 1 but not > 3 business days* 1 business day after all info; no more than 72 hours*
Home care after inpatient stay if next day Friday/holiday 72 hours after all info; no more than 3 business days* 72 hrs after all info but not > 3business days* 72 hours*
Inpt SUD requested 24 hrs prior to discharge from inpt admission N/A 24 hours of request 24 hours of request
Retrospective N/A (PHL 4903 standard applies) 30 days after all info
Reconsideration N/A (PHL 4903 standard applies) 1 business day
Other Actions
Authorization Decisions not Meeting Timeframe Requirements Date of timeframe expiration Date of timeframe expiration Date of timeframe expiration
Reductions, Terminations, Suspensions Notice at least 10 days in advance with exceptions (FH/aid continuing applies) Notice at least 10 days in advance with exceptions. (FH/aid continuing applies) Notice at least 10 days in advance with exceptions. (FH/aid continuing applies)
Payment Denials Notice on date of Action Notice on date of Action Notice on date of Action
Action Appeals
Filing Partial: 60 calendar days from date of Adverse Determination MA: Not < 60 business days (but not > 90 days) MAP: No less than 45 business days Not < 60 business days but not > 90 days 60 days from date of Adverse Determination
Acknowledgement 15 days 15 days 15 days
Resolution
Expedited 2 business days of all info but not > 3 business days* 2 business days after info but not > 3 business days* 2 business days after all info; not > 72 hours*
Standard 30 days* 30 days* 30 days*
Retro N/A (PHL 4904 standard applies) 30 days*
Notice
Expedited Oral notice at resolution Oral notice at resolution (written notice: PHL 4904 standard applies) At resolution; not > 72 hours*; written notice within 24 hours of determination
Standard Written notice within 2 business days of resolution Written notice within 2 business days of resolution Written notice within 2 business days of resolution; no longer than 30 days after receipt of appeal*
2nd Internal Appeal
Filing N/A (2nd level appeal optional) 2 nd level appeal not permitted
Acknowledgement N/A N/A N/A
Resolution
Expedited N/A N/A N/A
Standard N/A N/A N/A
Retro N/A   N/A
Notice
Expedited N/A N/A N/A
Standard N/A N/A N/A