| Three business days | We will render a decision for prior authorizations submitted electronically or by fax, and which include complete supporting documentation. |
| Three business days | For requests submitted without sufficient clinical documentation, a letter detailing what clinical information is needed will be sent to the member and the requesting provider within 3 business days. |
| Three business days | If the clinical information requested in a notice letter to the member and provider is not received by the end of the third business day from the date the notice was sent, the request may be denied. We will refer the request to a UnitedHealthcare medical director for a preemptive physician review with the requesting physician no later than the 7th business day from the date the request was received. The request will be decisioned no later than the 10th business day from receipt of the request. |
| Three business days | For requests where clinical information was requested, we will render a decision within 3 business days of receiving the requested information but no later than the 10th business day from receipt of the original incomplete request. |
| One business day | Concurrent hospitalization decision |
| One business day | For a member who is hospitalized at the time of the request for services or equipment that will be necessary for the care of the member immediately after discharge. |
| One hour | When submitted for post-stabilization or life-threatening conditions. Emergency medical and emergency behavioral health conditions do not require prior authorization. |
| 24 hours | For pharmacy prior authorization requests not submitted by phone, we’ll notify the prescriber’s office of a prior authorization denial or approval no later than 24 hours after receipt. |
| 24 hours | In the event that we cannot provide a response to a prior authorization request, or the prescriber is not available to make a prior authorization request because it is after the prescriber’s office hours, and the dispensing pharmacist determines it is an emergency situation, the pharmacy is allowed to dispense a 72-hour supply of the drug to the member. |
| 72 hours | When submitted by a provider of acute care inpatient services for services or equipment necessary to discharge the recipient from an inpatient facility. |
| 72 hours | Expedited request reviews |
| Immediately | When prescribers call the Pharmacy Help Desk for authorization. |
| 60 days | An existing authorization for services that may need to be continued can be requested to continue that service as a prior authorization with 60 days of the end of the previously approved authorization period. |
| Within 5 business days | Physical, occupational and speech therapies initial requests should be submitted within 5 business days from the date therapy treatments start |
| No more than 30 calendar days | Physical, occupational and speech therapies recertification requests should be submitted no more than 30 calendar days before the current authorization expires |
| Within 3 business days | Home health skilled nursing within 3 business days of the start of care after an assessment or evaluation in the member’s home |
| Within 3 business days | PDN (private duty nursing) initial requests should be within 3 business days of the start of care |
| At least 7, but no more than 30, calendar days | PDN recertification requests should be at least 7, but no more than 30, calendar days before the expiration of the current authorization |