Authorization and Referral Timelines

Hospitals Only

According to the utilization management (UM) standards - Commercial (PDF) or utilization management (UM) standards- Medicare Advantage (PDF), all hospitals are required to:

• Approve or deny and process 95 percent of all elective authorization requests within five days from the time of receipt of all clinical information
• Approve or deny and process 100 percent of all urgent requests for authorization within 24 hours
• Review 90 percent of all inpatient admissions daily
• Initiate 90 percent of all discharge planning within 24 hours of admission

For current standards, refer to the Industry Collaboration Effort (ICE) website at www.iceforhealth.org/library.asp to locate the Approved ICE Documents.

PPGs Only

According to the utilization management (UM) standards, all participating physician groups (PPGs) are required to:

• Approve or deny and process all routine authorization requests within the applicable regulatory time frame of the date of receipt of all information necessary to render a decision.
• If additional clinical information is required, the member and practitioner must be notified in writing within the applicable regulatory time frame of the extension.
• Communicate the decision to the member and practitioner within the applicable regulatory timeframe from the date of the original receipt of the request.
• Approve or deny and process all urgent requests for authorization within 72 hours after the receipt of the request for service.

The regulatory time frames begin when the delegated PPG's UM department receives a request for prior authorization. If the PPG's UM department receives a request for prior authorization of services and it is determined to be the plan's responsibility, the PPG must immediately forward the request to the plan as the regulatory time frames begin at the time of the original request. The commercial Informational Letter to Member or Provider/Physician carve-out letter(PDF) or Medicare Advantage Informational Letter to Member or Provider/Physician carve-out letter (PDF) serves to advise the member that the PPG's utilization management entity received a prior authorization request for which the PPG is not delegated to conduct a prior authorization review and notifies the member that the request has been forwarded to the plan. The regulatory time frame for the prior authorization review does not reset or stop when this letter is issued.

For additional information, refer to:

• Utilization Management Timeliness Standards - Medicare (PDF)
• Utilization Management Timeliness Standards - Commercial (PDF)