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Health NetMedicare Advantage · Prior Auth · Prior AuthorizationHigh impact

26-1071 Post-Decision Peer-to-Peer Reviews No Longer Available as a Method to Challenge Inpatient and Post-Acute Care Determinations

Act
by Nov 12, 2026
Effective date
Nov 12, 2026
Identified
Sep 10, 2026

Summary

Effective November 12, 2026, peer-to-peer (P2P) reviews can no longer be used to challenge adverse Medicare inpatient and post-acute care authorization determinations for Medicare Advantage and D-SNP plans. Providers must now submit reconsideration requests through the formal Medicare appeals process. Educational P2P discussions remain available but cannot change determination outcomes.

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What to do

by Nov 12, 2026 · 4 steps
01Billing and clinical teams must discontinue using peer-to-peer discussions as a method to appeal adverse inpatient and post-acute care authorization denials for Medicare Advantage and D-SNP plans.
02Instead, staff must submit all reconsideration requests through the formal Medicare appeals process using instructions in the adverse determination letter.
03Update internal appeal procedures, staff training materials, and provider communication templates to reflect this change.
04Ensure clinical staff understand that while educational P2P discussions remain available for clinical dialogue, they cannot be used to request determination reconsiderations.
If missed: Failure to follow the new appeals process may delay reconsideration reviews and result in claim denials being upheld.

Original notice

26-1071 Post-Decision Peer-to-Peer Reviews No Longer Available as a Method to Challenge Inpatient and Post-Acute Care Determinations
providerlibrary.healthnetcalifornia.com · Always check the source before changing claims.
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