26.1-36.12-05. Prior authorization - Nonurgent circumstances

26.1-36.12-05. Prior authorization - Nonurgent circumstances

1. If a prior authorization review organization requires prior authorization of a health care

service, the prior authorization review organization shall make a prior authorization or

adverse determination and notify the enrollee and the enrollee's health care provider of

the decision within seven calendar days of obtaining all necessary information to make

the decision. For purposes of this section, "necessary information" includes the results

of any face-to-face clinical evaluation or second opinion that may be required.

2. A prior authorization review organization shall have written procedures to address the

failure of a health care provider or enrollee to provide the necessary information to

make a determination on the request. If the health care provider or enrollee fails to

provide the necessary information to the prior authorization review organization within

fourteen calendar days of a written request for all necessary information, the prior

authorization review organization may make an adverse determination.

3. A prior authorization review organization shall allow an enrollee and the enrollee's

health care provider at least fourteen business days to request an updated prior

authorization following an unforeseen change in the circumstances or care needs for

the enrollee following a nonurgent circumstance or provision of health care services for

the enrollee.