Update Feb. 4, 2026: We're no longer offering the intent-to-deny P2Ps for Medicare inpatient acute authorizations (an informational P2P is available post-denial if desired). Providers who receive an authorization denial may still follow the appeals process. Providers may request a P2P for Medicaid inpatient acute authorizations up to 5 days post-denial. The table below has been updated to reflect these changes.
We’re working to align our utilization management (UM) processes for inpatient acute authorizations for Medicare and Medicaid, and to ensure we’re in compliance with both CMS regulations and state recommendations for HIDE-SNP implementation.
To meet this goal, we’re making the following updates to the processes for inpatient acute authorization requests once they’re submitted to us. These changes will go into effect on Jan. 1, 2026, unless otherwise noted.
Note: There is no change to the authorization submission process or to the commercial / ACA process, as outlined in our Provider Manual.
| Process element | Medicare Advantage | Medicaid |
| Priority Health sends a determination letter to the member within 72 hours of receiving the authorization request | Yes Per CMS regulation | Yes Per CMS regulation (started in Sept. 2025) |
| Provider may request a peer-to-peer (P2P) review | Informational only | Yes Available up to 5 days post-denial |
| Provider may submit a Level 1 medical necessity appeal to Priority Health | Yes No change | Yes No change |
| Provider may submit a Level 2 medical necessity appeal to Priority Health | No No longer permitted per CMS regulation | Yes No change |
| If Priority Health upholds a Medicare denial after the Level 1 appeal, we will automatically send the case to Medicare’s Independent Review Entity (IRE) for review. | Yes Per CMS regulation | N/A No change |