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42 CFR Ch. IV (10–1–09 Edition)§438.210

standing referral or an approved num-ber of visits) as appropriate for the en-rollee’s condition and identified needs.

§438.210Coverage and authorizationof services.

(a)

Coverage.

Each contract with anMCO, PIHP, or PAHP must do the fol-lowing:(1) Identify, define, and specify theamount, duration, and scope of eachservice that the MCO, PIHP, or PAHPis required to offer.(2) Require that the services identi-fied in paragraph (a)(1) of this sectionbe furnished in an amount, duration,and scope that is no less than theamount, duration, and scope for thesame services furnished to bene-ficiaries under fee-for-service Medicaid,as set forth in §440.230.(3) Provide that the MCO, PIHP, orPAHP—(i) Must ensure that the services aresufficient in amount, duration, orscope to reasonably be expected toachieve the purpose for which the serv-ices are furnished.(ii) May not arbitrarily deny or re-duce the amount, duration, or scope of a required service solely because of di-agnosis, type of illness, or condition of the beneficiary;(iii) May place appropriate limits ona service—(A) On the basis of criteria appliedunder the State plan, such as medicalnecessity; or(B) For the purpose of utilizationcontrol, provided the services furnishedcan reasonably be expected to achievetheir purpose, as required in paragraph(a)(3)(i) of this section; and(4) Specify what constitutes ‘‘medi-cally necessary services’’ in a mannerthat—(i) Is no more restrictive than thatused in the State Medicaid program asindicated in State statutes and regula-tions, the State Plan, and other Statepolicy and procedures; and(ii) Addresses the extent to which theMCO, PIHP, or PAHP is responsible forcovering services related to the fol-lowing:(A) The prevention, diagnosis, andtreatment of health impairments.(B) The ability to achieve age-appro-priate growth and development.(C) The ability to attain, maintain,or regain functional capacity.(b)

Authorization of services.

For theprocessing of requests for initial andcontinuing authorizations of services,each contract must require—(1) That the MCO, PIHP, or PAHPand its subcontractors have in place,and follow, written policies and proce-dures.(2) That the MCO, PIHP, or PAHP—(i) Have in effect mechanisms to en-sure consistent application of reviewcriteria for authorization decisions;and(ii) Consult with the requesting pro-vider when appropriate.(3) That any decision to deny a serv-ice authorization request or to author-ize a service in an amount, duration, orscope that is less than requested, bemade by a health care professional whohas appropriate clinical expertise intreating the enrollee’s condition or dis-ease.(c)

Notice of adverse action.

Each con-tract must provide for the MCO, PIHP,or PAHP to notify the requesting pro-vider, and give the enrollee written no-tice of any decision by the MCO, PIHP,or PAHP to deny a service authoriza-tion request, or to authorize a servicein an amount, duration, or scope thatis less than requested. For MCOs andPIHPs, the notice must meet the re-quirements of §438.404, except that thenotice to the provider need not be inwriting.(d)

Timeframe for decisions.

Each MCO,PIHP, or PAHP contract must providefor the following decisions and notices:(1)

Standard authorization decisions.

For standard authorization decisions,provide notice as expeditiously as theenrollee’s health condition requiresand within State-established time-frames that may not exceed 14 calendardays following receipt of the requestfor service, with a possible extension of up to 14 additional calendar days, if—(i) The enrollee, or the provider, re-quests extension; or(ii) The MCO, PIHP, or PAHP justi-fies (to the State agency upon request)a need for additional information andhow the extension is in the enrollee’sinterest.