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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)) (42 CFR 457.495(d))

Wisconsin’s performance-based contract provides as follows:

Qualified medical professionals must be involved in any decision-making that requires clinical judgment. The decision to deny, reduce or authorize a service that is less than requested must be made by a health professional with appropriate clinical expertise in treating the affected enrollee’s condition(s). Criteria used to determine medical necessity and appropriateness must be communicated to providers. The criteria for determining medical necessity may not be more stringent than HFS 101.03 (96m) Wis. Adm. Code.

HMO’s policies must specify time frames for responding to requests for initial and continued service determinations, specify information required for authorization decisions, provide for consultation with the requesting provider when appropriate, and provide for expedited responses to requests for authorization of urgently needed services. In addition, the HMO must have in effect mechanisms to ensure consistent application of review criteria for authorization decisions (interrater reliability).

a. Within the time frames specified, the HMO must give the enrollee and the requesting provider written notice of:

1) The decision to deny, limit, reduce, delay or terminate a service along with the reasons for the decision. 2) The enrollee’s right to file a grievance or request a state fair hearing.

b. Authorization decisions must be made within the following time frames and in all cases as expeditiously as the enrollee’s condition requires:

1) Within 14 calendar days of the receipt of the request, or 2) Within three business days if the physician indicates or the HMO determines that following the ordinary time frame could jeopardize the enrollee’s health or ability to regain maximum function. One extension of up to 14 calendar days may be allowed if the enrollee requests it or if the HMO justifies the need for more information.

WISCONSIN

Effective Date:

Approval Date: 39