Prior authorization timelines for service approvals and appeals
Customize your policy alerts
Sign up for all elderplan policy alerts
Know when elderplan releases new policies or updates existing guidance.
Monitor payer policy activity
This document governs timeframes Elderplan/HomeFirst uses to review prior authorization requests and appeals for services; it affects members and providers submitting those requests to Elderplan/HomeFirst.
No material clinical or coverage changes in this revision.
Authorization timing and decision criteria
Authorization Timing Criteria
Timeframe criteria for processing authorizations and appeals:
Relevant coding and timing values
| No specific billing, CPT, HCPCS, ICD-10, or other codes referenced in this document. |
Provider responsibilities and internal review timeframes
Prior Authorization and Review Timeframes
Elderplan/HomeFirst targets a standard internal review of prior authorization requests within 3 business days after required information is received; when clinical urgency or specified inpatient-to-post-acute transitions apply, an expedited review goal is 1 business day. Providers should submit all required supporting information promptly so the review can be completed within these timeframes; Elderplan/HomeFirst will notify the provider/member within 7 calendar days of a decision or to request additional information.
- Standard review goal: 3 business days when required information is received.
- Expedited review goal: 1 business day when urgent/clinical criteria are met or for inpatient-to-post-acute requests.
- Notification: Provider/member will be informed within 7 calendar days of a decision or request for more information.
Key term definitions
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.