Prior authorization decision timeframes
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This document sets timeframes for decisions on prior authorization and concurrent review requests for Elderplan/HomeFirst members and describes notification timing for additional information requests. It affects providers submitting authorization requests for member services.
No material clinical or coverage changes in this revision.
Authorization decision & notification timeframes
Authorization timing criteria
Decision and notification timeframes for authorization processes:
Concurrent review
- If additional information is needed during concurrent review, the requester will be notified within 7 days of receipt.
Inpatient rehabilitation (post‑admission)
- If additional information is needed for inpatient rehabilitation requests, the requester will be notified within 7 days of receipt.
Codes and key timing values
What providers need to know and do
Prior authorization standard review timeframe
Decision target for prior authorization requests is to render a determination within 3 business days of receipt of the request.
Requester notification when more information is needed
If additional information is needed to complete a prior authorization review, the requester will be notified within 7 days of receipt of the request.
Concurrent review timing and notifications
For concurrent reviews, a decision will be made once all required information is received; if more information is needed, the requester will be notified within 7 days of receipt.
Inpatient rehabilitation authorization timeframe
For inpatient-to-inpatient rehabilitation service requests following an inpatient admission, a decision will be made when all required information is received but no later than 7 days after receipt; notification that more information is needed will be provided within 7 days.
Defined timing terms
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.