PROVIDERS: For urgent or expedited pre-authorizations, please use the Pre-authorization Request Form—Clinically Urgent or Expedited, found at QualChoice.com. The patient must be in an urgent condition when using this form to request pre-authorization of services.
What is an urgent healthcare service?
An urgent healthcare service is a service for a clinical condition that, in the opinion of a physician with knowledge of the member’s medical condition, requires prompt medical care in order to prevent:
- a serious threat to life, limb or eyesight;
- worsening impairment of a bodily function that threatens the body’s ability to regain maximum function;
- worsening dysfunction or damage of any bodily organ or part that threatens the body’s ability to recover from the dysfunction or damage; or
- severe pain that cannot be managed without prompt medical care.
Examples of requests that might be considered clinically urgent:
- Treatment of cancer or acute infectious diseases
- Treatment of acute exacerbations of:
- Neurologic conditions (MS, Guillain-Barre, CIDP, myasthenia gravis)
- Systemic autoimmune diseases (Lupus, RA, psoriatic arthritis)
- Respiratory diseases (Asthma, COPD)
- Cardiovascular diseases (Arrhythmias, unstable angina/CAD, limb ischemia)
- Endocrine diseases (poorly controlled IDDM, Addison’s, thyroid storm)
Note: Urgent/expedited requests based on scheduling convenience could endanger other patients who have truly clinically urgent conditions. Providers will be informed if a QualChoice medical director determines that an urgent/expedited request is not truly clinically urgent and this will be recorded in the provider credentialing file. A pattern of inappropriate use of urgent/expedited requests may have credentialing/re-credentialing consequences. Urgent requests require a clinical rationale for urgency and attestation by signature of the ordering provider. If urgent status is not attested to by the provider (not office staff), the request will be considered routine.