Urgent Prior Authorization Requests; Access to Physicians

Urgent Prior Authorization Requests; Access to Physicians. To facilitate an Urgent Prior Authorization request in a timely manner as required by statute and this Rule, a health insurance issuer must establish a policy to ensure Health Care Professionals, defined as a physician, registered professional nurse or other individual appropriately licensed or registered to provide health care services, have access to appropriately trained and licensed clinical personnel who have access to physicians for consultation, designated by the plan to make such determinations for prior authorization concerning urgent care services. This policy must include the following: (1) Identification of the physicians available for consultation for each designated health service that requires prior authorization and contact information for those physicians. (2) Time frame for physicians to respond to Health Care Professionals or other clinical personnel. (3) Identification of the trained and licensed clinical personnel available for consultation for each designated health service that requires prior authorization and a method to contact said licensed clinical personnel. Identification may be made by providing the job title of the licensed clinical personnel. (4) The expertise required by the consulting physicians, which should take into consideration the physician’s specialty and experience as determined by the health care services requiring Urgent Prior Authorization. This policy is separate from the requirement of use of physicians qualified to review appeals. Such policy shall be submitted to the Department upon request.