Expedited Review

An expedited review is an accelerated appeal process available when a health plan's standard review timeframes would jeopardize the patient's health or ability to function. The plan is required to complete the review — and communicate the decision — within 72 hours (sometimes 24 hours in the most urgent cases), rather than the standard 30 to 60 days that applies to non-urgent appeals.

The right to expedited review is established under ACA regulations for group health plans and under state law for individual policies. It applies to prior-authorization denials, coverage-of-treatment denials, and mid-treatment terminations of care. The prescriber or treating clinician typically has to attest in writing that the standard review timeline would put the patient at serious risk — the plan can't require the patient to first exhaust the standard review process. Expedited external review (by an independent review organization) is also available when the expedited internal appeal is denied and the case still meets urgent criteria. In practice, expedited reviews are most commonly used for cancer treatment authorizations, mental health hospitalizations, and specialty drug prior authorizations for time-sensitive conditions. Plans that fail to meet the expedited review deadlines can face regulatory penalties and, on ERISA plans, litigation exposure.

The takeaway: if a treatment denial or coverage question is time-sensitive and could put you at real risk, ask the prescriber to file for expedited review specifically — with clinical documentation that the standard timeline is inadequate. The 72-hour clock is a legal requirement, not a courtesy.