o If insufficient information has been provided, a request for additional information will be made within one calendar day. • For electronic expedited prior authorization requests – within one calendar day o If insufficient information has been provided, a request for additional information will be made within one calendar day. • For nonelectronic standard requests – within five calendar days o If insufficient information has been provided, a request for additional information will be made within five calendar days. • For nonelectronic expedited requests - within two calendar days o If insufficient information has been provided, a request for additional information will be made within one calendar day. H. Recommended Treatment. KFHPWA’s medical director will determine the necessity, nature and extent of treatment to be covered in each individual case and the judgment will be made in good faith. Enrollees have the right to appeal coverage decisions (see Section VIII.). Enrollees have the right to participate in decisions regarding their health care. An Enrollee may refuse any recommended services to the extent permitted by law. Enrollees who obtain care not recommended by KFHPWA’s medical director do so with the full understanding that KFHPWA has no obligation for the cost, or liability for the outcome, of such care. New and emerging medical technologies are evaluated on an ongoing basis by the following committees – the Interregional New Technologies Committee, Medical Technology Assessment Committee, Medical Policy Committee, and Pharmacy and Therapeutics Committee. These physician evaluators consider the new technology’s benefits, whether it has been proven safe and effective, and under what conditions its use would be appropriate. The recommendations of these committees inform what is covered on KFHPWA health plans. I. Second Opinions. The Enrollee may access a second opinion from a Network Provider regarding a medical diagnosis or treatment plan. The Enrollee may request Preauthorization or may visit a KFHPWA-designated Specialist for a second opinion. When requested or indicated, second opinions are provided by Network Providers and are covered with Preauthorization, or when obtained from a KFHPWA-designated Specialist. Coverage is determined by the Enrollee's EOC; therefore, coverage for the second opinion does not imply that the services or treatments recommended will be covered. Preauthorization for a second opinion does not imply that KFHPWA will authorize the Enrollee to return to the physician providing the second opinion for any additional treatment. Services, drugs and devices prescribed or recommended as a result of the consultation are not covered unless included as covered under the EOC. J. Unusual Circumstances. In the event of unusual circumstances such as a major disaster, epidemic, military action, civil disorder, labor disputes or similar causes, KFHPWA will not be liable for administering coverage beyond the limitations of available personnel and facilities. In the event of unusual circumstances such as those described above, KFHPWA will make a good faith effort to arrange for Covered Services through available Network Facilities and personnel. KFHPWA shall have no other liability or obligation if Covered Services are delayed or unavailable due to unusual circumstances. K. Utilization Management. “Case management” means a care management plan developed for an Enrollee whose diagnosis requires timely coordination. All benefits, including travel and lodging, are limited to Covered Services that are Medically Necessary and set forth in the EOC. KFHPWA may review an Enrollee's medical records for the purpose of verifying delivery and coverage of services and items. Based on a prospective, concurrent or retrospective review, KFHPWA may deny coverage if, in its determination, such services are not Medically Necessary. Such determination shall be based on established clinical criteria and may require Preauthorization. KFHPWA will not deny coverage retroactively for services with Preauthorization and which have already been provided to the Enrollee except in the case of an intentional misrepresentation of a material fact by the patient, PEBB HMOHSA 2024 10