Authorization appeal effective June 2
Update May 7, 2025 - Updated to clarify that post-claim appeals / medical necessity review requests will still be allowed when a change was made to a previously authorized procedure.
Effective June 2, 2025, we won’t review post-claim appeals for medical necessity when a denied authorization is on file for the following authorization types, for all lines of business:
- Outpatient, home health & DME
- Elective inpatient
- Behavioral health
Note: This change doesn’t apply to inpatient acute / urgent / emergent or post-acute authorizations. Additionally, after June 2, you’ll still be able to appeal / request medical necessity review post-claim if a change was made to the procedure that was originally authorized.
This applies when you’ve requested an authorization, received a denial for medical necessity and performed the service or procedure. Services / procedures performed with a denied authorization become provider liability. This change is in alignment with industry standards.
Use your authorization appeal rights appropriately
We encourage you to take advantage of the authorization appeal rights available to you as appropriate:
- Two pre-service appeals are available (Levels 1 and 2) if you’ve received a denial on an authorization request and haven’t yet performed the service. Learn more.
- One post-service, post-claim medical necessity review is available if you performed the service but didn’t yet request authorization. In this case, you’d submit a claim and then follow our post-claim appeal process.