Expedited Organizational Determinations (Expedited Referral Requests)
Customize your policy alerts
Sign up for all astivahealth policy alerts
Know when astivahealth releases new policies or updates existing guidance.
Monitor payer policy activity
Defines Astiva Health's process, timeframes, and responsibilities for handling expedited organizational determinations (expedited referral requests) for members and delegated entities, applicable to Astiva Health Plan and delegated IPA/medical groups.
New policy created and approved by the Utilization Management Committee.
Expedited Determination Eligibility and Rules
Expedited Determination Eligibility and Timeframes
Expedited Organization Determinations are to be made when requested by authorized parties and within the specified timeframes:
Supported by policy definitions of eligible requestors
An extension may not be taken for Part B drug requests or when medical records cannot be obtained; if three documented good-faith attempts to obtain records fail, Astiva Health may deny for lack of established medical necessity.
Decision communication required by Astiva Health or delegate.
Responsibility for reviewing, authorizing, or denying is assigned to the appropriate health care professional.
An extension may not be taken for Part B drug requests. Astiva Health and delegated groups must complete an Expedited Organization Determination for Part B drug requests within 24 hours of receipt; the policy explicitly disallows taking an extension for these requests or when Astiva is unable to obtain medical records from a contracted provider. (See required timeframes and extension prohibition.)
If required medical information cannot be obtained, Astiva Health will make at least three (3) documented good-faith attempts to secure the records. If information is still not forthcoming after those attempts, Astiva Health may deny the request for lack of established medical necessity. Providers should supply a complete authorization request package with the clinical documentation outlined in the policy to avoid denial for missing documentation.
Expedited Decision Timeframes
Provider Responsibilities and Operational Rules
Expedited prior authorization timeframes — submit complete clinical documentation
Submit expedited prior authorization requests with complete clinical documentation; Astiva Health (or its delegate) will decide expedited Part C requests no later than 72 hours from receipt and expedited Part B drug requests no later than 24 hours from receipt, and will provide oral or written notification of the decision to the member and submitting provider within those timeframes.
- Expedited Part C: decision no later than 72 hours from receipt.
- Expedited Part B drug: decision and notification no later than 24 hours from receipt.
- Providers must include clinical documentation as part of the prior authorization submission.
Clinical review and specialist consultation — use approved criteria and consult when needed
Astiva Health uses approved criteria to evaluate requests and, when the Medical Director cannot decide from available information, may obtain consultation from a board-certified specialist in the same or similar specialty; responsibility for review, authorization, or denial will be assigned to the appropriate health care professional.
- Use approved clinical criteria for decisions.
- Medical Director may contact a board-certified specialist to assist decision-making.
- Decisions (approve, partially approve, deny) are assigned to the appropriate health care professional.
Required authorization documentation — submit a complete request package
Include a complete authorization request package with the member and provider identifiers, clinical details, and supporting documents as listed below; incomplete packages may delay processing of the expedited determination.
- Patient information: full name, date of birth, member ID.
- Provider information: name, contact, NPI, and professional credentials if required.
- Clinical documentation: short description and CPT codes for requested service; clinical records supporting medical necessity (diagnostic findings such as X‑rays, photographs, scans); a detailed treatment plan; relevant medical and dental history; any alternative treatments considered.
- Supporting documentation: specialist consultations, second opinions, or relevant peer‑reviewed research articles.
Denial after documented attempts for missing documentation
If Astiva Health has made at least three documented good‑faith attempts to obtain the required information and the information remains unavailable, the request may be denied for lack of established medical necessity.
- Document at least three good‑faith attempts to obtain missing records.
- Denial for lack of established medical necessity may be issued when requested information is still not forthcoming after those attempts.
Appeal and Reconsideration Notices
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.