CurrentQualChoicePolicy N/A

Clinically Urgent / Expedited Pre-authorization Requests

This document governs the process and required information for submitting urgent or expedited pre-authorization requests to QualChoice for members in North Carolina. It explains when an urgent request is appropriate and what provider attestation and documentation are required.

Policy Summary

PayerQualChoice

PolicyClinically Urgent / Expedited Pre-authorization Requests

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionUse the urgent/expedited pre-authorization form and include the ordering clinician's written attestation (signature and date) that the request meets urgent criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

urgent/expeditedform intended for

attestationordering clinician signature

examples listedclinical scenarios

checklistdocumentation

When to Use the Urgent/Expedited Pre-authorization Form

Use of Urgent/Expedited Pre-authorization Form

Use this form when ALL of the following are met:

Urgent form use

Clinical urgency definitions: Condition meets at least one of: a serious threat to life, limb, or eyesight; worsening impairment of bodily function that threatens ability to regain baseline; worsening dysfunction or damage of an organ/part that threatens recovery; or severe pain not manageable without prompt medical care
Determination based on clinician judgment and supported by clinical documentation
Illustrative examples of urgent conditions: Examples include treatment of dangerous or acute infectious diseases; acute exacerbations of neurological conditions (e.g., MS, Guillain‑Barré, CIDP, myasthenia gravis); systemic autoimmune diseases (e.g., lupus, RA, psoriatic arthritis); respiratory diseases (e.g., asthma, COPD); cardiovascular conditions (e.g., arrhythmias, unstable angina/CAD, limb ischemia); and endocrine crises (e.g., poorly controlled IDDM, Addison’s crisis, thyroid storm)
Examples are illustrative, not exhaustive

Policy Summary

PayerQualChoice

PolicyClinically Urgent / Expedited Pre-authorization Requests

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionUse the urgent/expedited pre-authorization form and include the ordering clinician's written attestation (signature and date) that the request meets urgent criteria.

SourceLink

On This Page

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Provider Attestation and Required Documentation

Prior Authorization

Urgent/Expedited Pre-authorization Attestation — This form must be used for urgent or expedited pre-authorization requests only; the ordering clinician must attest in writing (signature ...).

This form must be used for urgent or expedited pre-authorization requests only. The ordering clinician must attest in writing (signature and date) that the request meets urgent criteria. Read instructions carefully before completing the form — the patient must be in a true "urgent" clinical condition to use this form.

Documentation Required

PROVIDER ACTIONS — Attach documentation that supports the request; required items include place of treatment, evaluation/health history, office/therapy note...

Attach documentation that supports or facilitates your request. The following information is required for review — check all that apply and include copies with the request: place of treatment, evaluation/health history, office/therapy notes, and any other relevant clinical records.

Place of Treatment: Provider Office, Outpatient Facility, Inpatient Facility, Home Office, Other
Evaluation/Health History
Office/Therapy Notes

Denial Risk

PROVIDER ACTIONS — If a medical director determines that an urgent/expedited request is not truly urgent, providers will be informed and the request will be...

Urgent/expedited requests based on scheduling convenience that could endanger other patients or are not truly urgent will be downgraded to routine review. Providers will be notified if a medical director determines that an urgent/expedited request is not clinically urgent; this determination will be recorded in the provider credentialing file. Repeated inappropriate use of urgent/expedited requests may result in credentialing or re-credentialing consequences.

Documentation Required

Urgent/Expedited Pre-authorization Attestation — signature and date required

I, _____________________________ MD/PA/NP attest that the request for urgent pre-authorization meets the criteria and is documented and supported in the medical records. Physician/Provider Signature: _________________________ Date: __________

Context and Rationale

An urgent healthcare service is a non–life-threatening condition that, in the opinion of a clinician familiar with the member’s condition, requires prompt medical care to prevent a serious threat to life, limb, or eyesight; worsening impairment of bodily function; worsening dysfunction or damage to an organ or part; or severe pain not manageable without prompt care. Examples listed on the form include acute infectious disease treatment and acute exacerbations of neurological, systemic autoimmune, respiratory, cardiovascular, and endocrine conditions. For an urgent/expedited request, the form requires clinician attestation and supporting clinical documentation to justify the time-sensitive need.

Key Definitions

inv-08: Urgent healthcare service — definition

TermUrgent healthcare service

DefinitionA service for a non-life-threatening condition that, in the opinion of a clinician familiar with the member's condition, requires prompt medical care to prevent: a serious threat to life, limb, or eyesight; worsening impairment of bodily function that threatens ability to regain baseline; worsening dysfunction or damage to an organ or part that threatens ability to recover; or severe pain not manageable without prompt care.

Clinician requirementAssessment must be made by a clinician with knowledge of the member's medical condition (ordering clinician).

Clinical outcomes to preventSerious threat to life, limb, or eyesight; worsening impairment of body function; worsening organ dysfunction or damage; or severe uncontrolled pain.

ScopeApplies to non-life-threatening conditions that nevertheless need prompt intervention to avoid the listed harms.