Authorization timeframes for prior authorization requests
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This document sets the timelines Elderplan/HomeFirst uses to decide prior authorization requests and who is affected are members and requesters submitting authorization requests to Elderplan/HomeFirst.
No material clinical or coverage changes in this revision.
Authorization decision criteria
Authorization decision criteria
Decision timeframes and conditions
ALL of the following
- Standard (non-urgent) prior authorization requests: decision within 3 business days.
- Expedited/urgent prior authorization requests: decision within 1 business day.
- Inpatient post-hospitalization inpatient rehabilitation requests: decision within 1 calendar day.
ALL of the following
- If the reviewer needs additional information, the requester will be notified; the decision timeframe will not exceed 7 days from the request.
Prior authorization decision timeframes
Prior authorization decision timeframes
Elderplan/HomeFirst will decide prior authorization requests within the following timeframes when all required information is received. For standard (non‑urgent) non‑concurrent requests, a decision will be made within 3 business days; for expedited/urgent requests, a decision will be made within 1 business day. If additional information is needed, the requester will be notified and the decision will not exceed 7 days. For inpatient post‑hospitalization inpatient rehabilitation requests, a decision will be made within 1 calendar day when all required information is received, but the decision will not exceed 7 days if awaiting additional information.
- Standard (non‑urgent) requests: decision within 3 business days when all information received; will not exceed 7 days if additional information is needed and requester will be notified by day 7.
- Expedited/urgent requests: decision within 1 business day when all information received; will not exceed 7 days if additional information is needed and requester will be notified by day 7.
- Inpatient post‑hospitalization inpatient rehabilitation requests: decision within 1 calendar day when all information received; will not exceed 7 days if additional information is needed and requester will be notified by day 7.
Review type definitions and special cases
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.