described in subparagraph (B) or (C) of sub-
section (b)(1), by such earlier time as may be 
necessary to comply with the applicable timeline 
under such subparagraph. 
(B) LIMITED
EFFECT
OF
FAILURE
ON 
PLAN
OR
ISSUER’S
OBLIGATIONS.—Failure of 
the participant, beneficiary, or enrollee to com-
ply with the requirements of subparagraph (A) 
shall not remove the obligation of the plan or 
issuer to make a decision in accordance with 
the medical exigencies of the case and as soon 
as possible, based on the available information, 
and failure to comply with the time limit estab-
lished by this paragraph shall not remove the 
obligation of the plan or issuer to comply with 
the requirements of this section. 
(3) ORAL REQUESTS.—In the case of a claim 
for benefits involving an expedited or concurrent de-
termination, a participant, beneficiary, or enrollee 
(or authorized representative) may make an initial 
claim for benefits orally, but a group health plan, or 
health insurance issuer offering health insurance 
coverage, may require that the participant, bene-
ficiary, or enrollee (or authorized representative) 
provide written confirmation of such request in a
timely manner on a form provided by the plan or 
issuer. In the case of such an oral request for bene-
fits, the making of the request (and the timing of 
such request) shall be treated as the making at that 
time of a claim for such benefits without regard to 
whether and when a written confirmation of such re-
quest is made. 
(b) TIMELINE FOR MAKING DETERMINATIONS.— 
(1) PRIOR AUTHORIZATION DETERMINATION.— 
(A) IN GENERAL.—A group health plan, 
and a health insurance issuer offering health in-
surance coverage, shall make a prior authoriza-
tion determination on a claim for benefits 
(whether oral or written) in accordance with the 
medical exigencies of the case and as soon as 
possible, but in no case later than 14 days from 
the date on which the plan or issuer receives in-
formation that is reasonably necessary to enable 
the plan or issuer to make a determination on 
the request for prior authorization and in no 
case later than 28 days after the date of the 
claim for benefits is received. 
(B) EXPEDITED
DETERMINATION.—Not-
withstanding subparagraph (A), a group health 
plan, and a health insurance issuer offering
health insurance coverage, shall expedite a prior 
authorization determination on a claim for ben-
efits described in such subparagraph when a re-
quest for such an expedited determination is 
made by a participant, beneficiary, or enrollee 
(or authorized representative) at any time dur-
ing the process for making a determination and 
a health care professional certifies, with the re-
quest, that a determination under the proce-
dures described in subparagraph (A) would seri-
ously jeopardize the life or health of the partici-
pant, beneficiary, or enrollee or the ability of 
the participant, beneficiary, or enrollee to main-
tain or regain maximum function. Such deter-
mination shall be made in accordance with the 
medical exigencies of the case and as soon as 
possible, but in no case later than 72 hours 
after the time the request is received by the 
plan or issuer under this subparagraph. 
(C) ONGOING CARE.— 
(i) CONCURRENT REVIEW.— 
(I) IN
GENERAL.—Subject to 
clause (ii), in the case of a concurrent 
review of ongoing care (including hos-
pitalization), which results in a termi-
nation or reduction of such care, the 
plan or issuer must provide by tele-
phone and in printed form notice of 
the concurrent review determination 
to the individual or the individual’s 
designee and the individual’s health 
care provider in accordance with the 
medical exigencies of the case and as 
soon as possible, with sufficient time 
prior to the termination or reduction 
to allow for an appeal under section 
103(b)(3) to be completed before the 
termination or reduction takes effect. 
(II) CONTENTS
OF
NOTICE.— 
Such notice shall include, with respect 
to ongoing health care items and serv-
ices, the number of ongoing services 
approved, the new total of approved 
services, the date of onset of services, 
and the next review date, if any, as 
well as a statement of the individual’s 
rights to further appeal. 
(ii) RULE OF CONSTRUCTION.—Clause 
(i) shall not be construed as requiring 
plans or issuers to provide coverage of care