Utilization Management Timeliness Standards
Medical Precertification: |
Nonurgent |
Retrospective |
Expedited |
Initial decision-making and notification |
within 14 calendar days of receipt of request |
within 30 calendar days of receipt of request |
no later than 72 hours after receiving request |
Written notification of denial to member and provider if applicable |
within 14 calendar days of receipt of request |
within 30 calendar days of receipt of request |
no later than 72 hours after receiving request |
Written notification of approval to member and provider if applicable |
within 14 calendar days of receipt of request |
within 30 calendar days of receipt of request |
no later than 72 hours after receiving request |
Verbal notification of denial to member and provider if applicable |
within 14 calendar days of receipt of request |
No verbal notification |
no later than 72 hours after receiving request |
Pharmacy Precertification: |
Nonurgent |
Retrospective |
Expedited |
Initial decision-making and notification |
no later than 72 hours after receiving request |
within 30 calendar days of receipt of request |
no later than 24 hours after receiving request |
Written notification of denial to member and provider if applicable |
no later than 72 hours after receiving request |
within 30 calendar days of receipt of request |
no later than 24 hours after receiving request |
Written notification of approval to member and provider if applicable |
no later than 72 hours after receiving request |
within 30 calendar days of receipt of request |
no later than 24 hours after receiving request |
Verbal notification of denial to member and provider if applicable |
no later than 72 hours after receiving request |
No verbal notification |
no later than 24 hours after receiving request |