Authorization Requirements
Date: 02/08/17
Heritage Health (Medicaid):
Non-urgent, pre-service decisions (standard service prior authorization): Determinations for non-urgent, pre-service prior authorization requests are made within 14 calendar days of receipt of the request.
Urgent pre-service decisions (expedited prior authorization): Determinations for urgent pre-service care are issued within 72 hours of receiving the request for service.
Urgent concurrent (expedited continued stay): An urgent concurrent review is a request for services made while the member is in the process of receiving the care; typically associated with inpatient care or ongoing ambulatory care. Determinations for urgent concurrent continued stay review are issued within 24 hours of receipt of the request for services.
Post-service decisions (retrospective review): Medical necessity post-service decisions and subsequent written member and provider notification occur no later than 30 calendar days from receipt of the request.
Urgent care:
- Could seriously jeopardize the life or health of the member or the member’s ability to regain maximum function, based on a prudent layperson’s judgment, or jeopardize safety of the member or others due to the member’s psychological state, or
- In the opinion of a practitioner with knowledge of the member’s medical or behavioral health condition, would subject the member to adverse health consequences without the care or treatment that is the subject of the request.