MYTHBUSTER: Are MA plans required to respond to inpatient authorization requests?

MYTH: MA Plans are not required to respond to an inpatient authorization request.

FACT: MA Plans ARE required to respond to an inpatient authorization request.

Under 42 CFR §422.113(c)(2)(iii):

(2) MA organization financial responsibility. The MA organization:

(iii) is financially responsible for post-stabilization care services obtained within or outside the MAO that are not pre-approved by a plan provider or other MAO representative, but administered to maintain, improve, or resolve the enrollee’s stabilized condition if –

(A) the MAO does not respond to a request for pre-approval within 1 hour;

(B) the MAO cannot be contacted; or

(C) the MAO representative and the treating physician cannot reach an agreement concerning the enrollee’s care and a plan physician is not available for consultation. IN this situation, the MAO must give the treating physician the opportunity to consult with a plan physician and the treating physician may continue with the care of the patient until a plan physician is reached or one of the criteria in 422.113(c)(3) is met.

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