Prescription request that the provider submits additional information to make the prior authorization determination: Drug Services (EHB) (5)(a)(i)(C)(i) The issuer must give the provider forty-eight hours to (Cont’d) submit the requested information; WAC The issuer must then approve or deny the request within forty-eight hours of the receipt of the requested (5)(a)(i)(C)(ii) additional information and include the authorization number in its approval; 2020(5)(a)(ii) For nonurgent care review requests: WAC Must approve the request within five calendar days if the information is sufficient to approve the claim and include the (5)(a)(ii)(A) authorization number in its approval; WAC Must deny the request within five calendar days if the requested service is not medically necessary and the (5)(a)(ii)(B) information provided is sufficient to deny the claim; or WAC Within five calendar days, if the information provided is not sufficient to approve or deny the claim, the issuer must (5)(a)(ii)(C) request that the provider submits additional information to make the prior authorization determination: Requirement 2020(5) The issuer must give the provider five calendar days to to Maintain (a)(ii)(C)(I) submit the requested additional information; Drug 2020(5) The issuer must then approve or deny the request Utilization (a)(ii)(C)(II) within calendar days of the receipt of the additional Review information and include the authorization number in its Program approval. Publishing 45 CFR Plan must publish an up-to-date, accurate, and complete list of Formulary 156.122 all covered drugs on its formulary drug list, including any tiering (d)(1) structure and any restrictions on the manner in which a drug
Prescription Drug Services (EHB) (Cont’d) request that the provider submits additional information to make the prior authorization determination: (5)(a)(i)(C)(i) The issuer must give the provider forty-eight hours to submit the requested information; WAC (5)(a)(i)(C)(ii) The issuer must then approve or deny the request within forty-eight hours of the receipt of the requested additional information and include the authorization number in its approval; 2020(5)(a)(ii) For nonurgent care review requests: WAC (5)(a)(ii)(A) Must approve the request within five calendar days if the information is sufficient to approve the claim and include the authorization number in its approval; WAC (5)(a)(ii)(B) Must deny the request within five calendar days if the requested service is not medically necessary and the information provided is sufficient to deny the claim; or WAC (5)(a)(ii)(C) Within five calendar days, if the information provided is not sufficient to approve or deny the claim, the issuer must request that the provider submits additional information to make the prior authorization determination: Requirement to Maintain 2020(5) (a)(ii)(C)(I) The issuer must give the provider five calendar days to submit the requested additional information; Drug Utilization Review Program 2020(5) (a)(ii)(C)(II) The issuer must then approve or deny the request within calendar days of the receipt of the additional information and include the authorization number in its approval. Publishing Formulary 45 CFR 156.122 (d)(1) Plan must publish an up-to-date, accurate, and complete list of all covered drugs on its formulary drug list, including any tiering structure and any restrictions on the manner in which a drug
checklist-forms-2018-disability-individual-analyst-checklist.docx