Understanding when to submit standard vs urgent / expedited authorization requests

When submitting authorization requests and deciding whether to submit as standard or expedited, it’s essential to understand the criteria that define urgency.

By default, submit your requests as standard. Overuse of expedited requests can inadvertently lead to delays in review and denial decisions. If a case doesn’t meet the criteria for urgency (see below), submit it as a standard request.

Appropriate use of expedited requests

Expedited requests are reserved for cases that require immediate attention due to potential harm or life-threatening situations. This can include:

• Loss of life or limb: These cases involve imminent risk to life or limb (i.e., severe trauma, acute vascular emergencies, critical organ failure)
• Severe, intractable pain: Instances where patients experience intense, unmanageable pain that demands urgent intervention

Expedited elective inpatient requests

When submitting elective inpatient requests that meet urgent criteria, set your admission type to Elective Procedure and select an expedited authorization priority. Setting the admission type to Emergent inadvertently leads to delays in the review process, as it automatically routes the request to the incorrect Priority Health team.

By adhering to these guidelines, we can ensure an efficient authorization review process and better outcomes for our members, your patients. To learn more, see our GuidingCare Quick Start guide.