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Provider Manual

Utilization Management Timeliness Standards

Last Updated on July 01, 2022

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