Authorizations
Prior authorization, concurrent review, level-of-care criteria, peer-to-peer and single-case agreements.
Analysis — Aug 24
Original Medicare never concurrently reviews a PHP stay — it recertifies on day 18, then every 30 days
Concurrent review is where residential, PHP and IOP revenue is actually decided. The federal recertification cadence, the 24-hour ERISA clock on an extension request, what a reviewer reads, and who eats the days already delivered when authorisation lapses.
Analysis — Aug 23Medicare draws the IOP line at 9 hours a week and PHP at 20 — then prices both off the same per diem
Levels of care as payers actually adjudicate them: the hour thresholds in 42 CFR, the condition codes and APCs that separate PHP from IOP, the codes states use for residential and withdrawal management, and the four places the boundary gets fought.
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