Provider Network Responsibility to Comments Status Get Precertification precertification for all Inpatient Admissions. NOTE: For an Emergency Care admission, precertification is not required. However, you, your authorized representative or Doctor must tell us of the admission as soon as possible. How Decisions are Made We use our clinical coverage guidelines, such as medical policy, clinical guidelines, and other applicable policies and procedures to help make Medical Necessity decisions. This includes decisions about Prescription Drugs as detailed in the section “Prescription Drugs Administered by a Medical Provider”. Medical policies and clinical guidelines reflect the standards of practice and medical interventions identified as proper medical practice. We reserve the right, on behalf of the Employer, to review and update these clinical coverage guidelines from time to time. You are entitled to ask for and get, free of charge, reasonable access to any records concerning your request. To ask for this information, call the Precertification phone number on the back of your Identification Card. If you are not satisfied with the decision under this section of your benefits, please refer to the “Your Right To Appeal” section to see what rights may be available to you. Decision and Notice Requirements We will review requests for benefits according to the timeframes listed below. The timeframes and requirements listed are based on federal laws. If you live in and/or get services in a state other than the state where your Plan was issued other state-specific requirements may apply. You may call the phone number on the back of your Identification Card for more details. We will accept a request for Pre-service Reviews sent to us by your provider through secure electronic submission. Type of Review Timeframe Requirement for Decision and Notification Urgent Pre-service Review 72 hours or 2 business days from the receipt of request whichever is less Non-Urgent Pre-service Review 72 hours or 2 business days from the receipt of all necessary information whichever is less Urgent Continued/Concurrent Stay Review 24 hours from the receipt of the request when request is received more than 24 hours before the end of the previous authorization Urgent Continued/Concurrent Stay Review 72 hours from the receipt of the request or 2 business when request is received less than 24 hours days from the receipt of request whichever is less before the end of the previous authorization or no previous authorization exists Non-urgent Continued/Concurrent Stay 2 business days from the receipt of request Review for ongoing outpatient treatment Post-Service Review 2 business days from the receipt of request 39