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Expedited/Urgent Authorization Requests Tip Sheet

Date: 07/01/24

Sunshine Health wants to ensure that providers understand the definition of Expedited/Urgent Authorization requests.

Expedited/Urgent Service Authorization assignments are defined as requests that, if considered in a standard timeframe, could jeopardize the health or life of a member.

Submitting non-urgent requests as urgent can cause delays in processing as it floods our inventory with reviews that may not need urgent priority It also requires outreach to verify urgency when the request does not meet the definition. Knowing when to submit expedited/urgent requests and being proactive in your requests can help reduce delays in authorizations for all the care your patients need.

Examples of Proper Expedited/Urgent Authorization Requests

  • Life-saving procedures such as chemotherapy, dialysis, radiation, transfusions and wound care.
  • Office visits and outpatient programs (OP) for hospital follow-up appointments.
    • Example: A follow-up orthopedic appointment after visiting the emergency department (ED) for surgery/cast management.
  •  A member scheduled to undergo urgent surgery the day after being seen in a provider’s office; a surgical delay that could affect the member’s health.
  • A member being discharged from the hospital with orders for Home Health (HH) services.
  • Agency for Health Care Administration (AHCA) escalations.

Examples of Improper Expedited/Urgent Authorization Requests

  • A member who, after an office visit, needs elective surgery.
  • When a provider neglects to request services in a timely manner.
    • Note: Please do not attempt to speed-up a delayed/late request that was not submitted on time via the Expedited/Urgent Authorization Request process.
  • When a provider sends a request to the wrong vendor for review.
    • Note: In this instance, please do not try to make up for time by using the Expedited/Urgent Authorization Request process.
  • When a member transitions to a different provider.
    • Note: This is a common reason why Home Health (HH) agencies submit Expedited/Urgent Authorization Requests that do not meet the criteria to support this level of review.
  • When “urgent” is checked on the cover sheet but “standard” is selected on the authorization request form.
  • When a second, duplicate request is submitted as urgent.

Questions?

If you have any questions, please call Sunshine Health Provider Services at 1-844-477-8313 or visit the Secure Provider Portal. Our Provider Engagement staff are also here to help answer questions. Use the Find Your Administrator tool to confirm the individual supporting your specialty and region. We encourage you stay up to date on Sunshine Health provider notices by reviewing and bookmarking Provider News.

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