MA Script – Non-urgent Authorization Timeframes

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  • What date was the request for non-urgent authorization made?
  • Was there any written communication (request for information, denial, etc.) from the payor?
  • If so, how long after the request was made did you receive any written communication?
  • How many days is the plan in violation of the statutory authorization timeframe under 42 CFR §422.568(b)(1)?

The staff will be tactful and professional in communicating with the payer when making this firm call and request immediate compliance to the applicable code section:

Hi, my name is ____________________, this call may be recorded for compliance purposes. I’m calling to investigate a possible violation of 42 CFR §422.568(b)(1); can I give you a patient ID#?

This authorization request for non-urgent medical services was submitted on {REQUEST DATE} and is now {DAYS LATE} in violation of the statutory timeframes for prompt processing of non-urgent authorization requests. I have been asked to file a formal complaint with CMS citing {PLAN OR IPA}’s failure to issue a written determination to our authorization request within 14 calendar days, as required under federal law. I am calling to help {PLAN OR IPA} prevent any unnecessary regulatory action by providing an authorization for these services today.

Are you authorized to provide a hard copy authorization to bring your plan back into compliance?

I need to read you the following disclaimer: Your failure to issue an authorization for services requested by {FACILITY NAME} is a serious matter and violates patient rights and federal regulations designed to benefit the public. {PLAN}’s failure to issue a determination for our request to provide medically necessary services has a negative impact on the patient’s access to care. 

The provision of continuous quality health care in our region depends on {FACILITY NAME} receiving authorization for medically necessary services provided to patients.

Failure to comply with this telephonic notification of non-compliance to the applicable code section may result in a request for audit, investigation and the assessment of penalties by the Centers for Medicare and Medicaid Services.

I can resend you a copy of the original authorization request to help you avoid any sanctions and penalties for non-compliance, but this request will need to be processed on a “rush” basis.  What is your fax number?