Timely Notice of Appealable Actions

(A) Whenever an MCO, Accountable Care Partnership Plan, SCO Plan, One Care Plan, or the behavioral health contractor reaches a decision that constitutes an appealable action, as described in 130 CMR 610.032(B), it must send a notice to the member within the following time frames that describes its decision and its internal appeal procedures: (1) for a standard service authorization decision to deny or provide limited authorization for a requested service, no later than seven days following receipt of the request for service, unless the time frame is extended up to 14 additional days because the member or a provider requested the extension or the MCO, Accountable Care Partnership Plan, SCO Plan, and One Care Plan, or behavioral health contractor can demonstrate a need for additional information and how the extension is in the member’s interest; (2) for an expedited service decision to deny or provide limited authorization for a requested service, where a provider requests, or an MCO, Accountable Care Partnership Plan, SCO Plan, One Care Plan, or behavioral health contractor determines, that following the standard time frame in 130 CMR 508.011(A) could seriously jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function, no later than three business days after receipt of the request for service, unless the time frame is extended up to 14 additional calendar days because the member requested the extension or the MCO, Accountable Care Partnership Plan, SCO Plan, One Care Plan, or behavioral health contractor can demonstrate a need for additional information and how the extension is in the member’s interest; (3) for termination, suspension, or reduction of a previous authorization for a service, at least ten days before the action, except as provided in 42 CFR 431.213; and (4) for denial of payment where coverage of the requested service is at issue, on the day of the payment denial, except that no notice is necessary for procedural denials, which include, but are not limited to, the following: (a) failure to follow the MCO, Accountable Care Partnership Plan, SCO Plan, One Care Plan, or behavioral health contractor’s prior authorization procedures; (b) failure to follow referral rules; and (c) failure to file a timely claim. (B) Whenever an MCO, Accountable Care Partnership Plan, SCO Plan, One Care Plan, or the behavioral health contractor fails to reach a decision on a standard or expedited service authorization within the time frames described in 130 CMR 508.011(A)(1) and (2), whichever is applicable, it must send a notice to the member on the date that such time frame expires.