The premise of the utilization review exchange is that every request deserves a prompt response; instead, both medical organization and patients suffer through unnecessary, unprofessional and uncompassionate review processes.

The following quote from William Sage, in “Managed Care’s Crimea” (Duke Law Journal, 53: 593–666) establishes the importance of quality preauthorization responses:

“(P)hysicians give information to patients not only to help patients make decisions but to promote trust, which has both intrinsic health benefits and instrumental effects on health by inducing patients to share relevant facts about themselves with their providers and improving compliance with therapy. In particular, when doctors convey their professional opinion that a specific therapy is not advisable, they also maintain hope, offer explanations and alternatives, and assure patients that they will not abandon them. Health plans should try to follow this example when relaying determinations of medical necessity or other coverage matters. For example, written and oral communications denying coverage or requesting additional information should be compassionate, should be forthcoming about reasons for the health plan’s action, should take responsibility for the consequences instead of disclaiming them in anticipation of litigation, should offer alternatives to the denied treatment, and should avoid giving the impression of abandonment.”

It is up to providers to ensure that the patient is not abandoned and that pressure is placed on uncooperative insurers. Although some requests are more pressing than others, the urgency is not always communicated to the carrier who relies largely on the healthcare organization to determine whether the requested preauthorization should be expedited.

The Employee Retirement Income Security Act of 1974 (ERISA) claims procedure regulations are the most widely used standards regarding the time frames for response, and several accreditation agencies and even some state utilization mandates have been brought into synchronization with the ERISA requirements. This federal regulation applies to the majority of group health plans, with the exception of state and federal workers and certain religious organization health plans. It contains specific protections regarding time frames for group health plan responses to inquiries, as well as protections related to medical decision-making on claims. Therefore, it is a good attachment for stalled claims, prior authorization appeals, and medical necessity appeals involving applicable group health plans. It is available atwww.dol.gov/dol/allcfr/ebsa/Title_29/Part_2560/29CFR2560.503-1.htm. Because of its length, pertinent protections such as timing of benefit determination, disclosure requirements, and expert review procedures should be highlighted when submitted for consideration.

According to the ERISA regulation, all time frames start upon receipt of the request and must be answered as follows:

  • Nonurgent preservice decisions are compliant if the decision is made within 15 calendar days of the request
  • Urgent preservice decisions are compliant if the decision is made within 72 hours of receipt of the request
  • Urgent concurrent review decisions are compliant if the decision is made within 24 hours of receipt of the request
  • Post-service decisions are compliant if the decision is made within 30 calendar days of receipt of the request
  • Requests for additional information must be made within 24 hours of an incomplete urgent request and within five days of a nonurgent request
  • Notification of an incomplete request may be oral, unless written notification is requested by the claimant or authorized representative

Most important, it is up to you, not the carrier’s utilization review staff, to determine whether a preauthorization request, called a “preservice” claim under ERISA, is for urgent care. The ERISA definition is fairly broad in that it includes any signs and symptoms that “could seriously jeopardize the life or health of the claimant or the ability . . . to regain maximum function” or, in the opinion of a “physician with knowledge of the claimant’s medical condition,” would subject the claimant to “severe pain.” You should clearly identify precertification requests as nonurgent, urgent, urgent concurrent review, or post-service when seeking information.


Christine Taxin
Links2Success
36 Abington Avenue
Ardsley, New York 10502
United States of America