23 CAR § 141-104 – Medical provider office requirements for non-ACPA-approved team members

(a) A medical provider that is not on a nationally approved cleft-craniofacial team shall communicate and respond within two (2) working days from the request to any medical information requests made by the nationally approved cleft-craniofacial surgical team member who made the recommendation described in this part.
(b) For healthcare services that are recommended by a surgical team member of a nationally approved cleft-craniofacial team that are to be performed by a medical provider that is not on a nationally approved cleft-craniofacial team, a request for written authorization or approval shall be submitted to the health benefit plan:
1. (1) At least two (2) working days before the proposed service date as recommended by a nationally approved cleft-craniofacial surgical team member, for a nonurgent case; or
2. (2) Within twenty-four (24) hours before the proposed service date as recommended by a nationally approved cleft-craniofacial surgical team member, for an urgent case.
(c) The recommended needed services shall be the subject of an attestation delivered by a surgical team member of an ACPA-approved team to the medical provider and thereafter be monitored under the coordinated treatment plan until the completion of such services by the nationally approved cleft-craniofacial surgical team member.
(d) A medical provider that is not on a nationally approved cleft-craniofacial team shall comply with 23 CAR § 141-106 for referrals for services.
(e) The standards in this section shall follow the Prior Authorization Transparency Initiative.
(f)
1. (1) For claims to be admitted or paid under this section, for purposes of this section, a medical provider that is not on a nationally approved cleft-craniofacial team shall submit to the health benefit plan a signed attestation form (Exhibit A) by a surgical team member of an ACPA-approved team.
2. (2) The health benefit plan shall have two (2) working days from the submission date to review such claim or claims for nonurgent cases and twenty-four (24) hours for urgent cases.

Codification Notes: “ACPA” means American Cleft Palate-Craniofacial Association.