Urgent review of medical prior authorization requests

Priority Health places a time-sensitive priority on review of medical prior authorizations that are urgent. Urgent requests are defined using National Committee for Quality Assurance (NCQA) criteria. Urgent cases include the following:

• A delay in care could seriously jeopardize the life or health of the patient or the patient’s ability to regain maximum function.
• The opinion of a provider, with knowledge of the member’s medical condition, indicates a delay in care would subject the member to severe pain that cannot be adequately managed without the care or treatment requested in the prior authorization.

To be consistent in our processing of urgent requests, we will follow these criteria only. Please only note “urgent” on appropriate cases. By following this definition, Priority Health is able to respond more quickly with case review for members in greatest need of care.

Topics: Authorizations