Date

Attn: Director of Claims

[~Insurance Policy #1 Carrier~]

[~Insurance Policy #1 Address~]

                Re:          Patient:   [~Patient Name~]

                                Policy:   [~Insurance Policy #1 Number~]

                                Insured: [~Insurance Policy #1 Insured~]

                                Treatment Dates:  [~Admission Date~] - [~Discharge Date~]

                                Amount:  [~Total Charges~]

Dear Director of Claims,

According to our records, your company has been nonresponsive to our request for authorization of the above-referenced treatment.

 It appears that your company is an accredited member of URAC's utilization management program. As you are likely aware, URAC routinely reviews member organization’s operations to ensure that members are conducting business in a manner consistent with national standards agreed upon during the accreditation process. According to these standards, every URAC utilization management accredited organization must provide initial utilization management decisions within the following time frames:

For prospective review, the organization issues a determination within:

(a) 72 hours of the request for a utilization management determination, if it is a case involving urgent care; or

(b) 5 calendar days of the request for a utilization management determination, if it is a non-urgent case. (Standard UM 24)

For retrospective review, the organization issues a determination within 30 calendar days of the request for a utilization management determination. (This period may be extended one time by the organization for up to 15 calendar days, provided that such an extension is necessary due to matters beyond the control of the organization and notifies the consumer, prior to the expiration of the initial 30 calendar day period, of the circumstances requiring the extension of time and the date by which the organization expects to render a  determination.) (Standard UM 25)

For concurrent review, the organization issues a determination within:

(a) 24 hours of the request for a utilization management determination, if it is a case involving urgent care; or

(b) 4 calendar days of the request for a utilization management determination, if it is a non-urgent case. (Standard UM 26)

Please provide a copy of the authorization or denial determination. If a denial determination was rendered, please provide the name and credentials of the reviewing physician and information about what attempts were made for peer-to-peer discussion of this case. Thank you for your continued assistance in this matter.

Sincerely,

Claims Analyst