We’ve updated how we handle peer-to-peer conversations (P2P) for inpatient acute authorization denials for the following plans:
- Medicare Advantage
- D-SNP
- HIDE-SNP
You now have the opportunity for a P2P after the denial is issued; the P2P is informational only and cannot change the outcome. If you wish to dispute, you may submit an appeal.
What changed?
Under CMS regulations, these cases are “organization determinations.” We must send the member a determination letter within 72 hours of receiving the urgent authorization request, and the decision can’t be changed once the letter is in the mail.
On Jan. 1, 2026, we updated our P2P policy to comply with the CMS regulations noted above. To be a good network partner, we started offering an intent-to-deny P2P during 72-hour window when possible, to allow the conversation to happen before the denial. However, we’ve haven’t been able to do this consistently.
To ensure a clear, consistent process for both providers and our team, we’ve updated our process to offer an informational P2P after a denial has been issued.
What do you need to know?
You can still follow the appeal process to dispute denied authorizations. This includes one appeal right with Priority Health. If we uphold the denial, we’ll automatically send the case to Medicare’s independent review entity (IRE) for a second review.