In determining whether to approve, modify or deny requests by providers prior to, retrospectively, or concurrent with the provision of dental care services to members, Access follows the following processes:

Decision to approve, modify, or deny requests by providers prior to, or concurrent with, the provision of dental care services to members shall be made in a timely fashion appropriate to the nature of the member's condition, not to exceed five (5) business days from Access receipt of the information reasonably necessary and requested by Access to make the determination.

In cases where the review is retrospective, the decision shall be communicated to the individual who received services within 30 days of the receipt of the information that is reasonably necessary to make the determination. This information shall also be communicated to the provider.

When the member's condition is such that the member faces an imminent and serious threat to his or her health including, but not limited to, loss of life, or other major bodily function, the decision to approve, modify or deny requests by providers shall be made in a timely manner appropriate for the nature of the member's condition, not to exceed 72 hours after Access' receipt of the information reasonably necessary and requested by Access to make the determination.

Decision to approve, modify or deny requests by providers for authorization prior to, or concurrent with, the provision of dental care services to members shall be communicated to the requesting provider within 24 hours of the decision.

Except for concurrent review decisions pertaining to dental care that is underway, which shall be communicated to the enrollee's treating provider within 24 hours, decisions resulting in denial, delay, or modification of all or a part of the requested dental services, shall be communicated to the member in writing within two business days of the decision. In the case of concurrent review, dental care shall not be discontinued until the member's treating provider has been notified of Access' decision, and a care plan has been agreed upon by the treating provider that is appropriate for the dental needs of that patient.

In the event that Access cannot make a decision to approve, modify, or deny the request for authorization within the timeframes specified above because Access has not received all the needed information, Access shall then notify the provider and the member in writing that Access cannot make a decision to approve, modify or deny the request for authorization within the specified timeframe and specify the information requested but not received. Access shall also notify the provider and the member of the anticipated date on which a decision may be rendered.