Effective Sept. 1, 2026, you’ll no longer submit authorization requests for Medicare inpatient acute medical admissions.* We’ll instead implement a claim review process to confirm the appropriate level of care on some Medicare inpatient acute medical claims, focusing on shorter lengths of stay. This change will impact our Medicare plans only (including Medicare Advantage, D-SNP and HIDE-SNP).
*Note: authorization will still be required for behavioral health cases.
A simpler, more efficient process
Currently, we review 100% of Medicare inpatient acute cases for medical necessity through an authorization process, which is labor intensive for everyone involved.
By switching to a claim review process, we’re supporting:
- Elimination of authorization requirements at the point of admission, for Medicare inpatient acute cases (medical only)
- Reduced barriers to care
- Better alignment with industry movement
- Improved decision accuracy, with a stay’s full clinical picture available at the time of review
This initiative is grounded in federal regulations and CMS guidance, specifically 42 CFR § 412.3 (Admissions) and CMS’s "Two-Midnight Rule" (see 42 CFR § 412.3(d)).
What's not changing?
The following won’t be subject to this claim review:
- ICU admissions
- Member deaths
Additionally, established authorization processes for the following won’t change:
- Commercial inpatient acute cases
- Medicaid inpatient acute cases
- Scheduled Medicare inpatient cases
Claim review by a medical director, not automation
It’s important to note that a Priority Health medical director will determine level of care appropriateness for claims selected for review before payment . The decision process won’t be automated or based on an algorithm, and evaluation will be based on:
- InterQual guidelines, CMS criteria, plan medical policies
- Clinical documentation, if requested after claim submission
- Medical records accessed through direct EMR sharing
Get more information in our FAQ
We’ve put together a comprehensive FAQ with additional information about the Medicare inpatient acute claim review process. Access the FAQ online.