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including access to an adequate number of visits to specialists experienced in treating the specific medical condition and access to out-of-network providers when the network is not adequate for the enrollee’s medical condition. (Section 2102(a)(7)) (42CFR 457.495(c))

The health plan is required to maintain an adequate provider network including specialists. Access to specialty services will be monitored through periodic review of the number and types of providers by county, review of claims data, review of enrollee survey data, feedback from families and feedback from providers. In the rare instance that the provider network is not adequate to meet a member’s needs, the member will be referred out-of- network to obtain medically necessary services.

7.2.4 Decisions related to the prior authorization of health services are completed in accordance with state law or, in accordance with the medical needs of the patient, within 14 days after the receipt of a request for services. (Section 2102(a)(7)) (42CFR 457.495(d))

The health plan will be required to have policies in place to assure that prior authorizations of health services are completed within 14 days.

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