§ 417.609 - Expediting certain organization determinations.

Link to an amendment published at 70 FR 4713, Jan. 28, 2005.

(a) An enrollee, or an authorized representative of the enrollee, may request that an organization determination as defined in §§ 417.606(a)(3) and (a)(4) be expedited. The request may be made orally to the HMO or CMP.

(b) The HMO or CMP must maintain procedures for expediting organization determinations when, upon request from an enrollee or authorized representative of the enrollee, the organization decides that making the determination according to the procedures and time frames set forth in § 417.608(a)(1) could seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function.

(c) The procedures must include the following:

(1) Receipt of oral requests, followed by written documentation of the oral requests.

(2) Prompt decision-making regarding whether the request will be expedited, or handled within the standard time frame set forth at § 417.608(a)(1), including notification of the enrollee if the request is not expedited.

(3) Notification of the enrollee, and the physician as appropriate, as expeditiously as the enrollee's health condition requires, but within 72 hours of the request. An extension of up to 10 working days is permitted if requested by the enrollee or if the HMO or CMP finds that additional information is necessary and the delay is in the interest of the enrollee.

(i) Notification must comply with § 417.608(b), concerning the content of a notice of adverse organization determination.

(ii) If the initial notification is not in writing, written confirmation must be mailed to the enrollee within 2 working days.

(iii) In cases for which the HMO or CMP must receive medical information from a physician or provider not affiliated with the HMO or CMP, the time standard begins with receipt of the information.

(4) Granting the request of a physician, regardless of whether the physician is affiliated with the organization or not, to expedite the enrollee's request.

Effective Date Note:

At 70 FR 4713, Jan. 28, 2005, § 417.609 was removed, effective January 1, 2006.