Decisions regarding requests for authorization will be made only by licensed physicians or other appropriately licensed medical professionals.
Balance and its participating medical group have certain procedures that will make the authorization decision within the time frame appropriate for your condition, but no later than five business days after receiving all the information (including additional examination and test results) reasonably necessary to make the decision. Decisions about urgent services will be made no later than 72 hours after receipt of the information reasonably necessary to make the decision.
If the Medical Group needs more time to make the decision because it doesn’t have information reasonably necessary to make the decision, or because it has requested consultation by a particular specialist, you and your treating physician will be informed about the additional information, tests, or specialist that are needed, and the date that the Medical Group expects to make a decision. Your treating physician will be informed of the decision within 24 hours after the decision is made by telephone or facsimile. The plan will notify the physician and the Member in writing within two business days of making the determination.
If the Medical Group does not authorize all of the services, you will be sent a written decision and explanation within two business days after the decision is made. The letter will include information about your appeal rights, which are described in the “Grievance and Appeal Process” section of the Combined Evidence of Coverage and Disclosure Form. Any written criteria that the Medical Group uses to make the decision to authorize, modify, delay, or deny the request for authorization will be made available to you upon request. Once Balance authorizes a specific type of treatment by a provider, it shall not rescind or modify the authorization after the provider renders the health care service in good faith.