New York State Medicaid Managed Care Service Authorization and Appeals Timeframe Comparison

• Document also available in Portable Document Format (PDF)

Revised: February 2, 2018

	BBA Integration w/State Law CURRENT MLTC Partial Appendix K MAP Appendix F Med Adv Appendix F Actions	BBA Integration w/State Law CURRENT MMC Appendix F Actions	4/1/18 Mega Reg Integration w/State Law Appendix F Appendix K
Service Authorization Requests
Prior Authorization
Expedited	3 business days*	3 business days*	72 hrs*
Standard	3 business days after all info but not > 14 days*	3 business days after all info but not >14 days*	3 business days after all info but not > 14 days*
Certified Court MH/SUD Services	N/A	(PHL 4903 standard applies)	72 hrs*
Pharmacy	Immediate auth for 72 hour emergency supply	Immediate auth for 72 hour emergency supply; 7 day supply for opioid withdrawal/stabili-zation	24 hours; immediate auth for 72 hour emergency supply; immediate access to 5 day supply for SUD treatment medication (from INSL 3216, 3221, and 4303); immediate auth of 7 day supply for opioid withdrawal/ stabilization
Concurrent Review
Expedited	1 business day after all info; no more than 3 business days*	1 but not > 3 business days*	1 business day after all info; no more than 72 hours*
Standard	1 business day after all info; no more than 14 days*	1 business day but not > 14 days*	1 business day after all info; no more than 14 days*
Home care after inpatient stay	1 business day after all info; no more than 3 business days*	1 but not > 3 business days*	1 business day after all info; no more than 72 hours*
Home care after inpatient stay if next day Friday/holiday	72 hours after all info; no more than 3 business days*	72 hrs after all info but not > 3business days*	72 hours*
Inpt SUD requested 24 hrs prior to discharge from inpt admission	N/A	24 hours of request	24 hours of request
Retrospective	N/A	(PHL 4903 standard applies)	30 days after all info
Reconsideration	N/A	(PHL 4903 standard applies)	1 business day
Other Actions
Authorization Decisions not Meeting Timeframe Requirements	Date of timeframe expiration	Date of timeframe expiration	Date of timeframe expiration
Reductions, Terminations, Suspensions	Notice at least 10 days in advance with exceptions (FH/aid continuing applies)	Notice at least 10 days in advance with exceptions. (FH/aid continuing applies)	Notice at least 10 days in advance with exceptions. (FH/aid continuing applies)
Payment Denials	Notice on date of Action	Notice on date of Action	Notice on date of Action
Action Appeals
Filing	Partial: 60 calendar days from date of Adverse Determination MA: Not < 60 business days (but not > 90 days) MAP: No less than 45 business days	Not < 60 business days but not > 90 days	60 days from date of Adverse Determination
Acknowledgement	15 days	15 days	15 days
Resolution
Expedited	2 business days of all info but not > 3 business days*	2 business days after info but not > 3 business days*	2 business days after all info; not > 72 hours*
Standard	30 days*	30 days*	30 days*
Retro	N/A	(PHL 4904 standard applies)	30 days*
Notice
Expedited	Oral notice at resolution	Oral notice at resolution (written notice: PHL 4904 standard applies)	At resolution; not > 72 hours*; written notice within 24 hours of determination
Standard	Written notice within 2 business days of resolution	Written notice within 2 business days of resolution	Written notice within 2 business days of resolution; no longer than 30 days after receipt of appeal*
2nd Internal Appeal
Filing	N/A	(2nd level appeal optional)	2nd level appeal not permitted
Acknowledgement	N/A	N/A	N/A
Resolution
Expedited	N/A	N/A	N/A
Standard	N/A	N/A	N/A
Retro	N/A		N/A
Notice
Expedited	N/A	N/A	N/A
Standard	N/A	N/A	N/A

*Extension of up to 14 days permitted in certain circumstances.