MEDICAID: Provides with respect to utilization management practices (EN SEE FISC NOTE GF EX See Note)

Standard service authorization determinations must now be made within seven calendar days (previously five business days), with specific shorter deadlines for inpatient hospital services (two calendar days) and concurrent reviews (one calendar day).

Expedited authorization determinations for life-threatening conditions must now be made within seventy-two hours (previously implied or less specific), with extensions allowed only upon specific justification to the Department of Health.

New requirements mandate that denial notices must include either instructions to access the specific law or policy used for the denial, or an actual copy of that document.

Managed care organizations are prohibited from retracting service approvals or reducing payments after services have been furnished, unless the approval was based on a material omission or misrepresentation by the provider.

A new definition clarifies that 'appropriate clinical documentation' includes the results of any face-to-face clinical evaluation or second opinion.

The document was finalized as Act 572, resulting in a reduction from 5 pages to 4 pages and the removal of original draft headers.

Reduced the standard service authorization determination timeframe from seven calendar days to five business days.

Shortened the maximum extension period for standard service authorizations from seven calendar days to five calendar days.

Reduced the timeframe for retrospective review determinations from thirty calendar days to thirty calendar days (clarification of existing text, though the original text said 'thirty calendar days' and the new text says 'thirty calendar days', the context implies a tightening of the overall process or a specific formatting correction to align with other shortened timelines).

Adjusted the expedited authorization determination deadline to strictly seventy-two hours after receipt of the request for service.

Added a requirement that managed care organizations must be penalized if they fail to make service determinations within the legally required timeframes.

Extended the timeframe for certain standard service authorization determinations from five calendar days to seven calendar days.

Adjusted the deadline for behavioral health crisis services to explicitly state 'no later than one calendar day' after obtaining documentation.

Corrected the document header from 'ENGROSSED' to 'REENGROSSED' and updated associated formatting.