[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR457.1160]



[Page 424]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 457_ALLOTMENTS AND GRANTS TO STATES--Table of Contents

 

  Subpart K_State Plan Requirements: Applicant and Enrollee Protections

 

Sec.  457.1160  Program specific review process: Time frames.



    (a) Eligibility or enrollment matter. A State must complete the 

review of a matter described in Sec.  457.1130(a) within a reasonable 

amount of time. In setting time frames, the State must consider the need 

for expedited review when there is an immediate need for health 

services.

    (b) Health services matter. The State must ensure that reviews are 

completed in accordance with the medical needs of the patient. If the 

medical needs of the patient do not dictate a shorter time frame, the 

review must be completed within the following time frames:

    (1) Standard timeframe. A State must ensure that external review, as 

described in Sec.  457.1150(b), is completed within 90 calendar days of 

the date an enrollee requests internal (if available) or external 

review. If both internal and external review are available to the 

enrollee, both types of review must be completed within the 90 calendar 

day period.

    (2) Expedited timeframe. A State must ensure that external review, 

as described in Sec.  457.1150(b), is completed within 72 hours of the 

time an enrollee requests external review, if the enrollee's physician 

or health plan determines that operating under the standard time frame 

could seriously jeopardize the enrollee's life or health or ability to 

attain, maintain or regain maximum function. If the enrollee has access 

to internal and external review, then each level of review may take no 

more than 72 hours. The State may extend the 72-hour time frame by up to 

14 calendar days, if the enrollee requests an extension.