Prior Authorization Metrics for Medical Items and Services

To comply with the CMS Interoperability and Prior Authorization final rule, AvMed is required to annually report aggregated prior authorization metrics on our website. Specifically, this includes a list of all medical items and services (excluding drugs) that require prior authorization, as well as data on prior authorization requests for those items and services (e.g., approvals, denials, etc.) over the previous calendar year. Publicly reporting these metrics promotes transparency and accountability, helps patients understand prior authorization processes, and enables providers to evaluate payer performance. In addition, metrics can be used to compare plans, programs, and payers. For questions on the data below, contact us.

A list of medical items and services for which we require prior authorization (excluding drugs) can be found here: https://pal.avmed.com.

Authorization requests are processed promptly, based on the level of urgency determined by the member’s clinical condition.

Non-Urgent/ Standard pre-service request – A request submitted before a patient receives medical care or services. For commercial plans, the decision and notification will be completed within fifteen (15) calendar days.

Urgent/Expedited pre-service request – Urgent medical care is required for illnesses or injuries that need prompt attention. An expedited request is appropriate when waiting for the standard turnaround time could seriously jeopardize the member’s life, health, or ability to regain maximum function. For urgent care requests, the decision and notification will be completed within 72 hours of receiving the request.

Urgent Concurrent – A request for an ongoing course of treatment that requires immediate review. The decision and notification will be completed within 24 business hours of receiving the request.

Post-Service – A request for a decision regarding care or treatment that the patient has already received. For commercial plans, the determination and notification will be completed within thirty (30) calendar days.