Responding to Direct Requests By a Member for a Service. When a member requests a health or long-term care service or item, IDT staff shall do all of the following: Acknowledge receipt of the request and explain to the member the process to be followed in processing the request; Using the RAD or other Department approved guidelines, promptly determine what the core issue is in relation to the request. Assess if the request meets a need defined in the member’s long-term outcomes. Determine whether the request is for an item or service included in the Family Care Benefit package; if not, the MCO may authorize the service only if it complies with the requirements set forth in Article VII.A.7.; Promptly determine whether the IDT has the authority to authorize the requested service or whether the authorization decision must be made outside the IDT. See Article V.K.4., Service Authorization Decisions Made Outside the IDT; Consult as needed with other health care professionals who have appropriate clinical expertise in treating the member's condition or disease necessary to reach a service authorization decision. Issue a prompt decision as follows:
Appears in 4 contracts