Ariz. Admin. Code § R20-6-1910 - Process for Referral, Prior Authorization, Pre-certification, or Network Exception
A. An
HCSO shall have an effective process for assisting an enrollee to obtain timely
covered services when the enrollee or enrollee's referring provider cannot find
a contracted provider who is timely accessible or available.
B. An HCSO shall have an effective process
during normal business hours for handling referrals, prior authorizations,
pre-certifications, or network exceptions necessary for timely routine care.
This process may include the HCSO's procedure for standing referrals required
in A.R.S. §
20-1057.01.
C. Each HCSO shall have an effective process
to handle referrals or network exceptions necessary for timely urgent care
seven days a week.
D. An HCSO that
requires prior authorization or precertification for urgent care shall have an
effective process to handle requests for prior authorization or
precertification 24 hours a day, seven days a week.
E. An HCSO shall have an effective process
for handling network exceptions that ensures the HCSO reimburses an enrollee
for any out-of-network cost the enrollee incurs that the enrollee would not
have incurred if the enrollee had received the services in-network.
Notes
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