07/21/2023
We’ve recently been inundated with a huge increase in prior authorization (PA) requests. The increase in requests include an unusual number marked urgent or expedited. An urgent or expedited request, for members, is only appropriate for a situation that is:
- life threatening or
- poses a risk to maximum function
The problem: When non-urgent requests are marked urgent, they can over burden the review process by taking precedence over standard requests and creating a backlog, potentially delaying responses for legitimate urgent requests. This impacts your ability to service your patients in a timely manner.
The solution: Submit your PA requests with the appropriate documentation and level of urgency.
More information: Refer to the Utilization Management page on how to submit requestsand Prior Authorization Lists section of our provider website for information on what requires PA and how to submit. Always check eligibility and benefits through Availity® Essentials or your preferred vendor. Refer to our Eligibility and Benefits web page for more details.
Avoid post-service medical necessity reviews and delays in claim processing by obtaining prior authorization before rendering services or prescribing medications. If prior authorization is required, services performed and medications prescribed without prior authorization or that do not meet medical necessity criteria may be denied for payment or benefit coverage and the rendering provider may not seek reimbursement from the member.
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