Standard and Expedited Benefit Determinations
A benefit determination is any determination (i.e. approval or denial) by AmeriHealth Caritas Ohio regarding the benefits a member is entitled to receive from the Plan.
- Payment for emergency services, post-stabilization care, or urgently needed services.
- Payment for any other health service furnished by a non-contracted provider and the member believes:
- The services are covered under Medicaid program; or,
- If not covered under the Medicaid program, should have been furnished, arranged for or reimbursed by AmeriHealth Caritas Ohio.
- Refusal to authorize, provide or pay for services – in whole or in part – including the type or level of services, which the member believes should be furnished, arranged for, or reimbursed by the Plan.
- Reduction or premature discontinuation of a previously authorized on-going course of treatment.
- Failure of the Plan to approve, furnish, arrange for, or provide payment for health care services in a timely manner, or to provide the member with timely notice of an adverse determination, if the delay adversely affects the health of the member.
- The procedures for appealing an organization determination are described in the “Covered Services” section of the Provider Manual.
Standard determination decision turnaround time
AmeriHealth Caritas Ohio must notify the member of its determination as expeditiously as the member’s health condition requires, or no later than 10 calendar days after AmeriHealth Caritas Ohio receives the request. For adverse standard authorization decisions, written notification will be provided within three calendar days of the decision.
The timeframe may be extended up to 14 additional calendar days if:
- The provider or the member requests an extension; and,
- The Plan justifies the need for additional information and the extension is in the member’s best interest.
Urgent determination decision turnaround time
The member’s physician may request an expedited determination, including authorizations, from AmeriHealth Caritas Ohio when the member or physician believes waiting for a decision under the standard timeframe could seriously jeopardize the member’s life, health, or ability to regain maximum function.
In situations where a provider indicates or AmeriHealth Caritas Ohio determines that following the standard timeframe could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function, AmeriHealth Caritas Ohio will make an expedited authorization decision and provide notice as expeditiously as the member’s health condition requires and no later than 48 hours after receipt of the request for service.
If the member or member’s representative fails to provide sufficient information to determine whether, or to what extent, benefits are covered or payable, AmeriHealth Caritas Ohio will, within 24 hours of the receipt of the request, advise the member or member’s representative of the specific information necessary to make the determination.
AmeriHealth Caritas Ohio will allow the member or member’s representative at least 48 hours to provide the specified information, and will provide notification of the determination as soon as possible but not later than 48 hours after the receipt of the specified additional information or the end of the period afforded the member or member’s representative to furnish the additional information, whichever is earlier.
Unless otherwise provided by law, if AmeriHealth Caritas Ohio fails to respond to a member’s expedited prior authorization request within 72 hours of receiving all necessary documentation, the authorization is deemed to be granted and notice shall be given. In accordance with 42 C.F.R. § 438.404(c)(1), if the Plan intends to take an action to terminate, suspend, or reduce previously authorized Medicaid-covered services, AmeriHealth Caritas Ohio shall give notice of the adverse action at least 15 days before the date of action.
Continued/extended services decision turnaround time
For authorizations involving urgent care and relating to the extension of an ongoing course of treatment and involving a question of medical necessity, AmeriHealth Caritas Ohio will make a determinations within 24 hours of receipt of the request as long as the request is made at least 24 hours prior to the expiration of the prescribed period of time or course of treatment.
Authorization decisions not reached within the timeframes specified will result in a denial, and the Plan will give notice to the member as specified in rule 5160-26-08.4 of the Administrative Code.