CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Appropriate Use of Expedited Prior Authorization Requests

Governance of when and how Neighborhood Health Plan of Rhode Island processes expedited prior authorization requests and the timeframes and clinical rationale for using expedited versus standard processing; applies to providers submitting authorization requests to Neighborhood.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyAppropriate Use of Expedited Prior Authorization Requests

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJan 1, 2024

Next Review DateN/A

Key ActionSubmit expedited prior authorization requests only when one or more specified clinical criteria apply and include supporting documentation of the circumstances.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

14 daysstandard response timeframe

72 hoursexpedited response timeframe

3clinical criteria elements

When Expedited Processing Is Appropriate

Clinical Criteria for Expedited Requests

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ONE or more of the following must apply:

Processing the request within the standard timeframe will jeopardize the life or health of the member.
Processing within the standard timeframe will impact the member's ability to achieve or regain maximum function.
Processing within the standard timeframe will cause a barrier to transition of care.

Requesting an expedited/stat/urgent authorization without one of the above elements is discouraged.

Providers must provide supporting documentation when requesting expedited/stat/urgent review.

How Providers Should Submit Expedited Requests

Prior Authorization

When to request expedited prior authorization and required documentation

Submit an expedited (expedited/stat/urgent) prior authorization request only when one or more of the clinical criteria apply, and include supporting documentation that explains which criterion is met and the circumstances requiring urgent review.

Do not request expedited processing unless at least one of the following applies: processing within the standard 14‑day timeframe would (1) jeopardize the member’s life or health, (2) impact the member’s ability to achieve or regain maximum function, or (3) cause a barrier to transition of care.
Attach clinical documentation that demonstrates which criterion is met and why standard processing would be inadequate.
Select expedited processing only when these conditions are present; otherwise submit as a standard request (decision within 14 days).

Key Terms

inv-03: Expedited Request — definition and decision timeframe (72 hours)

DefinitionAn Expedited Request is an authorization request that must be decided within 72 hours from receipt because processing within the standard timeframe would jeopardize the member's life or health, impact ability to achieve or regain maximum function, or create a barrier to transition of care.

Decision timeframe72 hours from receipt of request.

When to useOnly when one or more clinical criteria apply: (1) standard processing would jeopardize life or health; (2) would impact ability to achieve/regain maximum function; (3) would create a barrier to transition of care.

Provider requirementDo not request expedited/stat/urgent authorization unless one or more of the above elements is applicable; provide supporting documentation when requesting expedited review.

inv-04: Standard Request — definition and decision timeframe (14 days)

DefinitionA Standard Request is an authorization request that is decided within 14 days from receipt of the request.

Decision timeframe14 days from receipt of request.

Use compared to expeditedStandard processing applies unless one or more expedited clinical criteria are met; expedited should only be requested when criteria are applicable.

Provider guidanceProviders should reserve expedited requests for situations meeting the specified clinical rationale and supply supporting documentation when requesting expedited review.