42 C.F.R. § 423.572 Timeframes and notice requirements for expedited coverage determinations.
Title 42 - Public Health
(a) Timeframe for determinations and notification. Except as provided in paragraph (b) of this section, a Part D plan sponsor that approves a request for expedited determination must make its determination and notify the enrollee (and the prescribing physician involved, as appropriate) of its decision, whether adverse or favorable, as expeditiously as the enrollee's health condition requires, but no later than 24 hours after receiving the request, or, for an exceptions request, the physician's supporting statement. (b) Confirmation of oral notice. If the Part D plan sponsor first notifies an enrollee of an adverse expedited determination orally, it must mail written confirmation to the enrollee within 3 calendar days of the oral notification. (c) Content of the notice of expedited determination. (1) The notice of any expedited determination must state the specific reasons for the determination in understandable language. (2) If the determination is not completely favorable to the enrollee, the notice must— (i) Inform the enrollee of his or her right to a redetermination; (ii) Describe both the standard and expedited redetermination processes, including the enrollee's right to request, and conditions for obtaining, an expedited redetermination, and the rest of the appeal process; and (iii) Comply with any other requirements specified by CMS. (d) Effect of failure to meet the adjudicatory timeframes. If the Part D plan sponsor fails to notify the enrollee of its determination in the timeframe specified in paragraph (a) of this section, the failure constitutes an adverse coverage determination, and the Part D plan sponsor must forward the enrollee's request to the IRE within 24 hours of the expiration of the adjudication timeframe.
Title 42: Public Health
PART 423—VOLUNTARY MEDICARE PRESCRIPTION DRUG BENEFIT
Subpart M—Grievances, Coverage Determinations, and Appeals
§ 423.572 Timeframes and notice requirements for expedited coverage determinations.
