IMPERATIVE-ACTION REQUIRED

Dear Director of :

This office has been asked to file a formal complaint with the Centers for Medicare and Medicaid Services (CMS) for ’s failure to meet the timeframe and notice requirements for non-urgent authorization requests as required by Federal law.

Our investigation has concluded the following:

THIS REQUEST IS NOW DAYS IN VIOLATION OF THE STATUTORY TIMEFRAMES.

Under existing Federal Law, 42 CFR §422.568(b)(1), Medicare Advantage organizations must meet the following requirements relating to the authorization of non-urgent services:

(b) Timeframes –

(1) Requests for service or item. Except as provided in paragraph (b)(1)(i) of this section, when a party has made a request for a service or an item, the MA organization must notify the enrollee of its determination as expeditiously as the enrollee’s health condition requires, but no later than 14 calendar days after the date the organization receives the request for a standard organization determination.

(i) Extensions; requests for service or item. The MA organization may extend the timeframe by up to 14 calendar days if –

(A) The enrollee requests the extension;

(B) The extension is justified and in the enrollee’s interest due to the need for additional medical evidence from a noncontract provider that may change an MA organization’s decision to deny an item or service; or

(C) The extension is justified due to extraordinary, exigent, or other non-routine circumstances and is in the enrollee’s interest.

(ii) Notice of extension. When the MA organization extends the timeframe, it must notify the enrollee in writing of the reasons for the delay, and inform the enrollee of the right to file an expedited grievance if he or she disagrees with the MA organization’s decision to grant an extension. The MA organization must notify the enrollee of its determination as expeditiously as the enrollee’s health condition requires, but no later than upon expiration of the extension.

At this point, we are requesting an immediate response to our request to prevent any further unnecessary regulatory complaint action.  Should you fail to comply with this notice, please be advised that we will expedite this matter before the Centers for Medicare and Medicaid Services (CMS) for your failure to release the authorization and/or federal funds intended for the Medicare beneficiary.

It is our sincere hope that it will not come to this point.

 

Sincerely,