Provider Resources

Medicare guidelines state that expedited processing may be requested when the enrollee or their physician believes that waiting for a decision under the standard time frame could place the enrollee’s life, health or ability to regain maximum function in serious jeopardy.

• Decision — 72 hours from request received date
• Provider notification — 72 hours from request received date
• Member notification — 72 hours from request received date

• Pharmacy expedited — 24 hours
• Pharmacy standard — 72 hours
• Retro — 14 calendar days

Criteria for services that require a prior authorization is available on request. Requested criteria will be faxed or emailed to the you.

Some criteria is available on the Medicare Coverage Database (MCD). Some services require a medical necessity review that may not be part of the NCD or LCD available on this website.  

The member's health plan, a list of service codes, and for procedure requests, inpatient or outpatient status, will be required to provide accurate criteria. 

Call 817-632-8602 to obtain a copy of the criteria.