Effective Jan. 1, 2026, we’ll offer peer-to-peer reviews (P2Ps) for Medicare inpatient acute authorizations before issuing a denial, rather than after. The window of opportunity for a P2P will be short, to comply with CMS-required turnaround times for expedited Medicare organization determinations.
Background
In compliance with CMS regulations, inpatient acute authorizations for our Medicare members will be defined as organization determinations effective Jan. 1, 2026. Under Medicare organization determination rules, a decision can’t be changed after a denial has been issued and a denial letter has been sent to the member.
What’s changing?
While we’ll no longer be able to offer post-denial P2Ps for Medicare inpatient acute authorizations, we still want to offer our provider network a P2P opportunity and will shift to an intent-to-deny P2P.
CMS allows a 72-hour window from the time a health plan receives an expedited Medicare organization determination request (i.e., inpatient acute authorization) to when the decision letter must be in the mail to the member.
If we determine a request doesn’t meet InterQual® criteria for an inpatient acute setting, we’ll immediately offer the opportunity for an intent-to-deny P2P by:
- Sending an intent-to-deny notice through our GuidingCare authorization portal and
- Making one phone call attempt to the contact person / number listed on the authorization request – if the call is missed and voicemail is available, we’ll leave a message with our direct P2P line
If you miss the short window to hold a P2P, you’ll still have two levels of appeal available to you.
More to come
In the coming weeks, we’ll update the appeals process information available in our Provider Manual to reflect this change.