Urgent and Life‑Threatening Policy
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Defines Aloha Care's definition of urgent/life‑threatening cases and the process for designating prior authorizations as urgent; applies to Aloha Care and its delegates and to providers requesting expedited review.
No material clinical or coverage changes in this revision.
Urgent and Life‑Threatening Case Criteria
Urgent case criteria and process
Covered when ALL of the following are met:
ALL of the following
ONE of
- Condition that without immediate attention could seriously jeopardize the life or health of the consumer or the ability of the consumer to regain maximum function
- Based on the physician's opinion, the consumer would be subjected to severe pain
- A physician with knowledge of the consumer's medical condition determines it is a case involving urgent care
- Provider must request that a prior authorization be designated as urgent; AlohaCare and its delegates will not proactively ask whether an authorization is urgent
- If the provider designates the authorization as urgent, AlohaCare and its delegates will follow the standard expedited handling process
AlohaCare and its delegates will not ask if the authorization is urgent; provider must request designation
Provider Requests and Expedited Handling
Provider must request urgent designation
Providers must request that a prior authorization be designated as urgent; AlohaCare and its delegates will not proactively ask if an authorization is urgent when a provider calls in. A provider must explicitly ask for urgent designation to obtain expedited handling.
- AlohaCare and its delegates can designate prior authorizations as urgent upon provider request.
- AlohaCare and its delegates will not ask if the authorization is urgent if a provider calls in.
Expedited handling after urgent designation
If the provider designates the authorization as urgent, AlohaCare and its delegates will follow the policy's standard expedited handling process for urgent cases.
- Standard expedited criteria: (1) condition that could seriously jeopardize life or health or ability to regain maximum function; (2) physician opinion that the consumer would be subjected to severe pain; (3) a physician familiar with the consumer's condition determines it is urgent.
- Designation by the provider triggers the standard handling process.
Key Definitions
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