Prior approval process explained

By Stacy Austin,2014-04-17 23:05
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Prior approval process explained

    Prior approval process for GPs Brighton and Hove City Teaching PCT

    Prior Approval Process

    Process for GPs

    Prior approval should never delay clinically necessary treatment.

    This process applies regardless of which hospital the patient may be referred

    to and only applies to referrals to secondary care.

    When you identify a patient whose condition may suggest treatment which is

    on the prior approval list:

    1. Check the procedure is on the list on the PCT website. A list of all

    procedures can be found on the PCT website at


2. Is the procedure on the list?

    No refer to secondary care through the usual route

    Yes check the policy for this procedure and assess the patient

    against the policy.

3. Does the patient meet the criteria within the policy?

    No please do not refer. If the patient does not meet the criteria in the

    policy, the PCT will not fund the procedure. Please explain the criteria

    and evidence base for this policy to the patient. You may also want to

    download the Patient Brochure

    priorapprovalspublic.asp to help patients understand why the PCT

    makes evidence based and prioritising decisions. If you think the

    patient has exceptional circumstances, you may apply through the

    Exceptional Cases Panel. See the policy and information on this on the

    PCT website.

    Yes download and complete the application form for the procedure.

    Most procedures have a specific application form with a list of the

    criteria a patient needs to meet for a decision to be made by the PCT.

    If there is no application form, it is because the procedure is not

    normally funded. Please check the policy for details. You may be able

    to make an application to the PCT Exceptional Cases Panel.

    PLEASE NOTE: At this stage this is not a referral, it is a pre-referral

    decision process. Please explain this to the patient so that expectations

    about treatment are not raised.

    4. Send the application form to the address on the form. You can do this

    by fax or email (only via email address) or as a last resort, by


    15 May 2008


Prior approval process for GPs Brighton and Hove City Teaching PCT

    5. You will receive an acknowledgement of receipt of the application as

    soon as it is received by the Prior Approval Team. This

    acknowledgement will be by email. When the PCT receives the

    application the 18 weeks clock will starting ‘ticking’.

    6. The PCT will review the application. The PCT will make a decision and

    notify you within 3 working days.

    7. If the application is approved you will receive a copy of the application

    with the approval number. You can then refer to secondary care in the

    normal way, but please attach a copy of the application form with your

    referral letter. If you do not attach this approved application form,

    secondary care will not be able to carry out the procedure.

    8. If the application is declined the PCT will send you and the patient a

    letter explaining the decision.

    If you would like an opinion on a patient’s condition (that may necessitate a prior approval procedure) you can refer in the usual way asking for an opinion. However, if the secondary care clinician suggests a treatment or procedure or the prior approval list, you will still have to apply to the PCT for approval. If the patient does not meet the criteria, you may be able to apply through the Exceptional Cases Panel. Please note that going through this process is likely to raise expectations of treatment, necessitate a secondary care appointment and potentially add time to the 18 weeks target.

    If you have any questions about this process or the policies please contact:

NHS Funded Care Team (Prior Approvals)

    Brighton and Hove City Teaching PCT

    Level 4,

    Lanchester House,

    Trafalgar Place, Brighton BN1 4FU

Tel: 01273 295490

    Fax: 01273 574737


    15 May 2008


Prior approval process for GPs Brighton and Hove City Teaching PCT

    Prior Approval/Exceptions Process

     Patient presents at GP practice

     Clinician checks against Prior Approval list of treatments

    Treatment required does appear

    on Prior Approval list

    Treatment required is

    not on prior approval list

    Does the patient meet the

    criteria/ threshold for treatment?

    Refer in usual way

    Yes No Clock starts when secondary

    care receive the referral

    Refer to PCT Prior Does the patient have

    Approval team exceptional circumstances? Clock Starts when PCT receives No Yes application. Team confirms that patient

    meets criteria/ threshold for treatment

    End and Clock Stop

    Yes No

    GP constructs case outlining

    exceptional circumstances and sends to

    PCT Exceptional Cases Panel GP notified and Sent back to GP.

    refers to Clock Stops

    secondary care Clock Starts when PCT receives application

    Exceptional Exceptional

    circumstances are circumstances are

    agreed not agreed Activity

    measured and

    audited by PCT Patient informed of Referral to BSUH

    outcome and by GP

    advised of appeal 15 May 2008 process 3

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