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) |
If Priority Health finds the authorization request doesn’t meet InterQual® criteria, we will offer the provider an intent-to-deny peer-to-peer (P2P) opportunity during a short window before the member determination letter is mailed | Yes Announced in Nov. 2025, can’t change denial for Medicare organization determinations | Yes Per HIDE-SNP recommendation; also aligns government programs |
| 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 |
Intent-to-deny notification
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:
- In-network providers: Sending an intent-to-deny notice through our GuidingCare authorization portal
- Out-of-network providers: Making one phone call attempt to the contact person / number listed on the authorization request
If you miss the short window to hold a P2P, you may appeal the decision per the process outlined above.