Three business days
For prior authorizations submitted electronically or by fax, and which include complete supporting documentation
One business day
Concurrent hospitalization decision
One business day
For a member who is hospitalized at the time of the request for services or equipment that will be necessary for the care of the member immediately after discharge
When submitted for post-stabilization or life-threatening conditions. Emergency medical and emergency behavioral health conditions do not require prior authorization.
For pharmacy prior authorization requests not submitted by phone, we’ll notify the prescriber’s office of a prior authorization denial or approval no later than 24 hours after receipt.
In the event that we cannot provide a response to a prior authorization request, or the prescriber is not available to make a prior authorization request because it is after the prescriber’s office hours, and the dispensing pharmacist determines it is an emergency situation, the pharmacy is allowed to dispense a 72-hour supply of the drug to the member.
When submitted by a provider of acute care inpatient services for services or equipment necessary to discharge the recipient from an inpatient facility
Expedited requests reviews
When prescribers call the Pharmacy Help Desk for authorization
An existing authorization for services that may need to be continued can be requested to continue that service as a prior authorization with 60 days of the end of the previously approved authorization period.
16 business hours
If medical necessity supporting documentation is not received for our members 20 and younger, a letter is sent to the member letting them know which medical necessity supporting documentation was not sent to us so we can review a prior authorization request for need.
7 calendar days
A letter is sent to member if authorization is denied with notification of rights to appeal.