Section 2: Expedited vs. Standard Processing

16.2.1 The “Why”: Clinical Urgency is the Deciding Factor

You have now mastered the legal clocks that govern prior authorization. The next critical skill is learning how to switch from the standard clock to the urgent one. The distinction between a Standard and an Expedited (or “Urgent”) request is not based on convenience, provider preference, or patient frustration. It is based on a single, powerful concept: clinical exigency. Is there a risk of significant, negative health outcomes if the patient has to wait the full standard timeframe for a decision?

As a pharmacist, your clinical judgment is paramount in making this determination. You are often the first person to see the full picture: the prescription, the patient’s diagnosis, their medication history, and the context of their clinical situation. A provider might simply want to get a patient started on a new therapy, but you may be the one to recognize that delaying this specific therapy for 7 to 14 days could lead to hospitalization, disease progression, or irreversible harm. Your role is to identify these situations and effectively communicate the clinical risk to both the prescriber and the payer to justify an expedited review.

Invoking the expedited pathway is the single most powerful tool you have to accelerate access to care. However, it is a tool that must be used judiciously and with proper justification. Overusing expedited requests for non-urgent situations can lead to a “crying wolf” scenario, where payers begin to scrutinize your urgent submissions more heavily. Conversely, failing to request an expedited review when clinically warranted is a major patient safety risk. This section is a deep dive into the art and science of this decision. We will move beyond the regulatory definitions and into the practical, clinical scenarios you will face every day, equipping you with the framework and language to confidently and effectively determine when to push the “urgent” button.

16.2.2 Deconstructing the Definition of “Urgent”

The CMS definition provides the legal framework: a situation where a delay could “seriously jeopardize the patient’s life, health, or ability to regain maximum function.” This is intentionally broad, allowing for clinical judgment. Your job is to translate this legal language into concrete clinical scenarios. An expedited request is not just for life-or-death situations; it also applies to conditions that could rapidly worsen, cause significant pain, or lead to a decline in function.

Masterclass Table: Clinical Scenarios Warranting Expedited Review

Clinical Category	Example Scenarios	Justification Language: “Why it’s Urgent”	Pharmacist’s Role & Key Questions
Acute, Severe Conditions	A new prescription for an anticoagulant for a patient newly diagnosed with a DVT or PE. An antiviral for a patient with shingles to prevent postherpetic neuralgia. An antibiotic for a serious infection that is not responding to first-line therapy.	“Delay in therapy places the patient at high risk of thrombus propagation and embolization.” “Initiation of antiviral therapy within 72 hours of rash onset is critical to reduce the risk of debilitating postherpetic neuralgia.”	Your role is to immediately recognize the time-sensitive nature of the drug. Is this for an acute diagnosis? Is there a window for optimal efficacy? You must coach the provider’s office to include this justification in the PA submission.
Uncontrolled, Severe Symptoms	A non-formulary antipsychotic for a patient with schizophrenia experiencing acute psychosis. A potent opioid for a cancer patient with breakthrough pain not controlled by their current regimen. A new biologic for a patient with a severe, debilitating flare of rheumatoid arthritis or Crohn’s disease.	“Patient is experiencing acute psychosis and is a danger to self or others; immediate stabilization is required.” “Patient has uncontrolled, severe cancer pain (10/10) leading to functional incapacitation; a standard 7-day review would cause undue suffering.”	Here, the focus is on the severity of symptoms and the impact on function and safety. Your questions should be: How severe is the pain/symptom? Is the patient able to perform activities of daily living? Is there a safety risk (e.g., falls, self-harm)?
Prevention of Rapid Disease Progression	Continuation of an immunosuppressant for a recent organ transplant recipient. Starting a disease-modifying antirheumatic drug (DMARD) for rapidly progressing, erosive rheumatoid arthritis. A specialty medication to prevent relapse in a patient with multiple sclerosis.	“Interruption of immunosuppressive therapy in a post-transplant patient could lead to acute organ rejection and graft loss.” “Patient has evidence of active joint erosion; a delay in initiating a DMARD could result in irreversible joint damage and permanent disability.”	This requires foresight. The risk may not be immediate in the next hour, but a 7-14 day delay could be catastrophic. Your job is to articulate the long-term consequences of a short-term delay. A lapse in therapy for a transplant patient is a five-alarm fire.
Hospital Discharge Medications	A new starter-pack of an expensive oral chemotherapy agent. A new anticoagulant for a patient post-cardiac stent placement. An injectable antipsychotic for a patient being discharged from a psychiatric facility.	“Patient is pending discharge from the hospital. Timely access to this medication is required to ensure a safe transition of care and prevent readmission.”	Discharge PAs are Almost ALWAYS Urgent This is a critical category. A patient cannot be safely discharged without assurance they can obtain their critical medications. Delaying discharge costs the hospital thousands of dollars per day and increases the patient’s risk of nosocomial infections. Therefore, any PA that is holding up a hospital discharge should be filed as expedited.

16.2.3 The Mechanics of Requesting an Expedited Review

Simply thinking a request is urgent is not enough. You must take specific, deliberate steps to ensure the payer processes it as such. Failing to follow the correct procedure will result in the request being triaged as standard, regardless of the clinical situation. The process involves two key phases: justification and communication.

Phase 1: Building the Justification

Before you even submit the request, you must have a clear and compelling reason for the urgency. This is your “statement of need.”

Phase 2: Executing the Submission

How you submit the request matters. Different portals and forms have specific ways to flag a case as urgent.

Submission Method	How to Flag as “Expedited”	Pharmacist Pitfall to Avoid
Electronic PA (ePA) Portals (e.g., CoverMyMeds, Surescripts)	Most ePA portals have a dedicated checkbox or dropdown menu at the beginning of the form labeled “Expedited,” “Urgent,” or “Stat.” You must select this option. Many portals will then open a mandatory text box requiring you to enter the clinical justification for urgency.	The Fatal Flaw: Simply writing “Please expedite” in the general clinical notes section without checking the official “Urgent” box. The system’s automated triage will likely miss this note and default the case to a standard queue. You must use the designated field.
Payer-Specific Web Portals	Similar to ePA platforms, these portals almost always have a specific radio button or checkbox to indicate urgency. It is often located on the first page of the request form. You must actively look for it.	Assuming the payer will “figure it out” from the clinical context. They will not. Payer systems are designed for high-volume processing. If the “expedite” flag is not triggered in their system, it will be treated as standard.
Fax Submission	This is the most error-prone method. You must make the urgency impossible to miss. Use a fax cover sheet with “URGENT – EXPEDITED REVIEW REQUESTED (72-HOUR TAT)” in large, bold, 24-point font at the top. Hand-write the same message at the top of the payer’s PA form itself. Ensure the provider’s supporting statement of urgency is on the first page of the clinical notes.	Burying the request for expedition on page 12 of the clinical notes. The person triaging the incoming faxes may never see it. The first page is the most valuable real estate.
Telephone PA (Calling the Payer)	This is a direct and effective method for urgent cases. State your intention at the very beginning of the call.	Weak Opening: “Hi, I’m calling to start a prior auth…” Strong Opening: “Hi, my name is [Name], a pharmacist calling on behalf of Jane Doe. I need to initiate a clinically urgent, expedited prior authorization request for Eliquis.” Using the magic words “urgent” and “expedited” upfront immediately routes your call and the subsequent case to the correct, accelerated pathway.

16.2.4 When the Payer Disagrees: Downgrades and Your Response

You have gathered the clinicals, collaborated with the provider, and submitted a perfectly justified expedited request. However, the plan can still disagree. A payer has the right to review your justification for urgency and, if they determine it does not meet the regulatory standard, downgrade the request to a standard review timeframe. This is a frustrating but legal maneuver. When this happens, they must notify the provider and member of the decision and the reason for the downgrade.

This is a critical juncture where your advocacy skills are put to the test. Your response should be immediate, professional, and strategic.