Authorization and Referral Timelines
Provider Type
- Participating Physician Groups (PPG)
According to utilization management (UM) standards, all participating physician groups (PPGs) are required to:
- Approve, modify, deny or process all routine authorization requests within the lesser of five business days or seven calendar days (whichever results in the earlier due date) of the date of receipt of all information necessary to render a decision.
- Approve, modify, deny or process all urgent and/or expedited requests for authorization within 72 hours after the receipt of the request for service.
- Make a determination within 24 hours of receipt of an urgent-concurrent authorization request provided that the request is made at least 24 hours prior to the expiration of the previously approved period of time or number of treatments. In the cases of urgent-concurrent review, care will not be discontinued until the treating provider has agreed to a care plan appropriate for the medical needs of the enrollee.
If additional clinical information is required, an initial decision may be deferred (extension) for 14 calendar days from the date of receipt of the original request if the referring provider, treating provider, or triaging health professional has determined and noted in the relevant record that a longer waiting time will not have a detrimental impact on the health of the enrollee, in accordance with Section 1367.03(a)(5)(H), and:
- Additional clinical information is required.
- Consultation by an expert reviewer is required.
- Additional examination or tests are required.
- The member and practitioner must be notified in writing within the applicable regulatory time frame of the extension.
- Additionally, advise the requesting provider that in accordance with Health and Safety Code Section 1367.03(a)(h)(5):
- If this delay to obtain additional information will have a detrimental impact on the health of the member, you must contact the Plan.
- If this delay will not have a detrimental impact on the health of the member, you must document this in the member record.
Deferral/extension timeliness standards
- Routine (pre-service) requests:
- If the provider has not complied with the request for additional information by the anticipated decision date, the PPG reviews the request with the information available and makes a determination by the 14th calendar day from receipt of the original request.
- If the requested information is received, a decision must be made within five business days or seven calendar days (whichever results in the earlier due date) of receipt of complete information.
- Urgent/expedited (pre-service) requests:
- If the provider has not complied with the request for additional information by the anticipated decision date, the PPG reviews the request with the information available and makes a determination by the 14th calendar day from receipt of the original request.
- Urgent-concurrent requests:
- Extensions are allowed only under the following conditions:
- If the review request for extension of services was not made at least 24 hours prior to the expiration of the previously approved prescribed period of time or number of treatments, the PPG may treat the review request as an urgent pre-service review request determination and make the decision within the regulatory timeline of 72 hours from receipt of request.
- If additional information is required, the PPG must adhere to the extension process for extending time frames for urgent/expedited requests. An additional 48 hours is afforded to the facility to provide the additional information. However, the PPG’s determination must be made within 24 hours of receipt of information or expiration of the extension, not to exceed 72 hours from receipt of original request.
- Extensions are allowed only under the following conditions:
- Communicate the decision to the member and practitioner within the applicable regulatory time frame from the date of the original receipt of the request.
- For cases where expert consultation is required to make an initial decision
Type of request | Notification |
|---|---|
Non-urgent pre-service | If a consultation is required by an expert reviewer, upon the expiration of the lesser of five business days or seven calendar days or as soon as Health Net becomes aware that the lesser of five business days or seven calendar days time frame will not be met, practitioner and member will be notified of the type of expert reviewer and the anticipated date on which a decision will be rendered (no more than 14 calendar days from the date of the delay notice to the practitioner and member). |
Post-service | If a consultation is required by an expert reviewer, upon expiration of 30 calendar days, or as soon as Health Net becomes aware that the 30-calendar day time frame will not be met (whichever occurs first), the practitioner and member will be notified of the type of expert reviewer and the anticipated date on which a decision will be rendered (within 30 days of the receipt of information reasonably necessary to make this determination per HSC 1367.01(h)(1) ) |
If a consultation is required by an expert reviewer, upon expiration of 30 calendar days, or as soon as Health Net becomes aware that the 30-calendar day time frame will not be met (whichever occurs first), the practitioner and member will be notified of the type of expert reviewer and the anticipated date on which a decision will be rendered (within 30 days of the receipt of information reasonably necessary to make this determination per HSC 1367.01(h)(1) ). The Notice of Action About Your Treatment Request letter (PDF) serves to advise the member that the PPG's utilization management entity received a prior authorization request but the PPG is not delegated to conduct a prior authorization review and the PPG notifies the member that the request has been forwarded to the Plan. The regulatory time frame for the prior authorization review does not reset or stop when this letter is issued.
The National Committee for Quality Assurance (NCQA) counts the time from the date when Health Net receives the request, regardless of whether it is during business hours. Non-urgent requests may be processed on the next business day.