How long do authorizations take?
In compliance with Health and Safety Code Section 1367.01(h)(2), HPSM will decide routine pre-approvals within 5 working days of when HPSM gets the information reasonably needed to decide.
For requests in which a provider indicates or HPSM determines that following the standard timeframe could seriously jeopardize your life or health or ability to attain, maintain, or regain maximum function, HPSM will make an expedited (fast) authorization decision. HPSM will give notice as quickly as your health condition requires and no later than 72 hours after receiving the request for services.
Pre-approval requests are reviewed by clinical/medical staff, such as doctors, nurses and pharmacists. Reviewers use current clinical guidelines to meet state and national standards to decide if the request is medically necessary.
HPSM does not pay the reviewers to deny coverage or services. If HPSM does not approve the request, HPSM will send you a Notice of Action (NOA) letter. The NOA letter will tell you how to file an appeal if you do not agree with the decision.
HPSM will contact you and your provider if HPSM needs more information or more time to review your request.