Expedited Requests: Prior Authorization

Expedited requests for prior authorization are based upon the medical condition of the beneficiary. Reasons that are a reflection of additional documentation submitted, supplier financial status, etc. will not be processed as expedited.

For additional information, please review the FAQs below:

The patient is discharged from the hospital with an order for repetitive transports that begin within 48 hours of discharge. We provide the four initial transports right away within a few days. The Prior Authorization (PA) request takes ten business days to come back and we have provided more than the initial four transports. Can we submit this as an expedited PA request?

Answer: If the transports are for dialysis only:

  • These are typically ordered on a Monday-Wednesday-Friday or Tuesday-Thursday-Saturday rotation
  • If the patient is only using repetitive trips for dialysis, they should have all the documentation in order prior to leaving the hospital
  • If dialysis begins on day two, the fifth round trip should be around day eight after discharge. You should receive the decision on the PA request by the 10th business day.
  • You would also have the option of providing the service, billing it and receiving an Additional Documentation Request (ADR). As long as the transports meet medical necessity requirements, they should be allowed
  • Fax and esMD submission will achieve faster turn-around time. Requesting the decision by fax is also an option on the PA request form.

If the transports are also for something else, such as wound care:

  • It is anticipated that wound care is managed in the home and requires only periodic clinic appointments for debridement, wound management, infection types of services. In this situation an expedited request would not be necessary

I submitted an expedited Prior Authorization (PA) request. What happens if it does not qualify for expedited processing? Do I need to send another PA request?

Answer: No, you do not need to submit another request. If it is determined that the submitted information does not support expedited processing, your request will be moved to the regular PA request workload to be processed as normal.

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Provider Contact Center: 855-696-0705

TDD: 866-830-3188

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