Urgent/Emergent Prior Authorization Requests

As a reminder regarding prior authorization (PA) requests, please be careful when indicating whether or not a request is truly urgent/emergent.  We have seen an unusually large increase in requests where indication has been marked urgent that do not fit the definition and guidelines for such.  Please see below how PacificSource defines “urgent/emergent”.  Please contact your Provider Service Representative if you have any questions.

Urgently Needed Care: Urgently needed care is care

provided to treat a non-emergency, unforeseen medical

illness, injury, or condition that requires immediate medical

care. Urgently needed care may be furnished by in-network

providers or by out-of-network providers when in-network

providers are temporarily unavailable or inaccessible.

Nonemergent Condition: Routine medical care such

as diagnostic work-ups for chronic conditions, elective

surgery, and scheduled follow up visits for prior emergency

conditions.