[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR438.210]



[Page 229-230]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 438_MANAGED CARE--Table of Contents

 

        Subpart D_Quality Assessment and Performance Improvement

 

Sec.  438.210  Coverage and authorization of services.



    (a) Coverage. Each contract with an MCO, PIHP, or PAHP must do the 

following:

    (1) Identify, define, and specify the amount, duration, and scope of 

each service that the MCO, PIHP, or PAHP is required to offer.

    (2) Require that the services identified in paragraph (a)(1) of this 

section be furnished in an amount, duration, and scope that is no less 

than the amount, duration, and scope for the same services furnished to 

beneficiaries under fee-for-service Medicaid, as set forth in Sec.  

440.230.

    (3) Provide that the MCO, PIHP, or PAHP--

    (i) Must ensure that the services are sufficient in amount, 

duration, or scope to reasonably be expected to achieve the purpose for 

which the services are furnished.

    (ii) May not arbitrarily deny or reduce the amount, duration, or 

scope of a required service solely because of diagnosis, type of 

illness, or condition of the beneficiary;

    (iii) May place appropriate limits on a service--

    (A) On the basis of criteria applied under the State plan, such as 

medical necessity; or

    (B) For the purpose of utilization control, provided the services 

furnished can reasonably be expected to achieve their purpose, as 

required in paragraph (a)(3)(i) of this section; and

    (4) Specify what constitutes ``medically necessary services'' in a 

manner that--

    (i) Is no more restrictive than that used in the State Medicaid 

program as indicated in State statutes and regulations, the State Plan, 

and other State policy and procedures; and

    (ii) Addresses the extent to which the MCO, PIHP, or PAHP is 

responsible for covering services related to the following:

    (A) The prevention, diagnosis, and treatment of health impairments.

    (B) The ability to achieve age-appropriate growth and development.

    (C) The ability to attain, maintain, or regain functional capacity.

    (b) Authorization of services. For the processing of requests for 

initial and continuing authorizations of services, each contract must 

require--

    (1) That the MCO, PIHP, or PAHP and its subcontractors have in 

place, and follow, written policies and procedures.

    (2) That the MCO, PIHP, or PAHP--

    (i) Have in effect mechanisms to ensure consistent application of 

review criteria for authorization decisions; and

    (ii) Consult with the requesting provider when appropriate.

    (3) That any decision to deny a service authorization request or to 

authorize a service in an amount, duration, or scope that is less than 

requested, be made by a health care professional who has appropriate 

clinical expertise in treating the enrollee's condition or disease.

    (c) Notice of adverse action. Each contract must provide for the 

MCO, PIHP, or PAHP to notify the requesting provider, and give the 

enrollee written notice of any decision by the MCO, PIHP, or PAHP to 

deny a service authorization request, or to authorize a service in an 

amount, duration, or scope that is less than requested. For MCOs and 

PIHPs, the notice must meet the requirements of Sec.  438.404, except 

that the notice to the provider need not be in writing.

    (d) Timeframe for decisions. Each MCO, PIHP, or PAHP contract must 

provide for the following decisions and notices:

    (1) Standard authorization decisions. For standard authorization 

decisions, provide notice as expeditiously as the enrollee's health 

condition requires and within State-established timeframes that may not 

exceed 14 calendar days following receipt of the request for service, 

with a possible extension of up to 14 additional calendar days, if--

    (i) The enrollee, or the provider, requests extension; or

    (ii) The MCO, PIHP, or PAHP justifies (to the State agency upon 

request) a need for additional information and how the extension is in 

the enrollee's interest.



[[Page 230]]



    (2) Expedited authorization decisions. (i) For cases in which a 

provider indicates, or the MCO, PIHP, or PAHP determines, that following 

the standard timeframe could seriously jeopardize the enrollee's life or 

health or ability to attain, maintain, or regain maximum function, the 

MCO, PIHP, or PAHP must make an expedited authorization decision and 

provide notice as expeditiously as the enrollee's health condition 

requires and no later than 3 working days after receipt of the request 

for service.

    (ii) The MCO, PIHP, or PAHP may extend the 3 working days time 

period by up to 14 calendar days if the enrollee requests an extension, 

or if the MCO, PIHP, or PAHP justifies (to the State agency upon 

request) a need for additional information and how the extension is in 

the enrollee's interest.

    (e) Compensation for utilization management activities. Each 

contract must provide that, consistent with Sec.  438.6(h), and Sec.  

422.208 of this chapter, compensation to individuals or entities that 

conduct utilization management activities is not structured so as to 

provide incentives for the individual or entity to deny, limit, or 

discontinue medically necessary services to any enrollee.



                    Structure and Operation Standards