What Is Concurrent Review? (How Insurers Monitor Ongoing Treatment)
Learn what concurrent review is, how insurers use it to cut short hospital stays and ongoing treatment, and what you can do when concurrent review results in a denial.
What Is Concurrent Review?
Concurrent review is a type of utilization review that occurs while you are actively receiving medical treatment — typically during a hospital stay or ongoing course of care. Unlike Prior Authorization Denied: How to Appeal" class="auto-link">prior authorization (which happens before treatment starts) or retrospective review (which happens after), concurrent review is performed in real time as your care is being delivered.
During a concurrent review, your insurer evaluates whether continued treatment is medically necessary and whether it should continue to be covered. The insurer may approve continued days in the hospital, request additional information from your care team, or issue a denial of continued coverage.
How Does Concurrent Review Work?
Here is the typical concurrent review process:
1. Notification of admission or ongoing care. When you are admitted to a hospital or begin a course of treatment requiring authorization, your provider notifies your insurer. For emergency admissions, notification is usually required within 24 to 48 hours.
2. The insurer assigns a case manager or nurse reviewer. A clinician employed by the insurer reviews your medical records, treatment plan, and diagnosis against internal clinical criteria (commonly InterQual or Milliman Care Guidelines).
3. The insurer makes an ongoing coverage determination. The reviewer approves a specified number of days or treatment units and schedules a follow-up review date. You and your provider receive notice of approved coverage.
4. Renewal reviews occur periodically. As your treatment continues, the insurer conducts additional reviews — sometimes daily during a hospitalization — to decide whether to keep approving coverage.
5. A denial can be issued at any point. The insurer may determine that continued inpatient care is no longer medically necessary and issue a notice of non-coverage for future days.
What Happens When Concurrent Review Results in a Denial?
A concurrent review denial means your insurer will stop paying for your care as of a specific date. This does not necessarily mean you must leave the hospital — your physician controls medical discharge, not your insurer. However, you may become financially responsible for costs after the denial date if you remain.
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You have the right to appeal a concurrent review denial immediately. Under federal law (for ERISA plans and ACA-compliant plans), you must receive advance notice of the denial and have the opportunity to request an expedited appeal before coverage ends.
Key rights during a concurrent review denial:
- Expedited internal appeal: You can request a same-day or next-day expedited review by the insurer's medical director.
- Expedited External Independent Review: Complete Guide" class="auto-link">external review: If the internal appeal is denied, you can request an independent external review, often with a decision within 72 hours.
- Physician-to-physician review: Your doctor has the right to speak directly with the insurer's reviewing physician before the denial is finalized.
- Continued coverage pending appeal: In some states and plan types, coverage must continue during an expedited appeal of a concurrent review denial.
What Criteria Do Insurers Use in Concurrent Review?
Insurers most commonly use third-party clinical criteria tools, including:
- InterQual: Developed by Change Healthcare (now part of Optum), used by many commercial insurers and Medicare Advantage plans.
- Milliman Care Guidelines (MCG): Published by Milliman, widely used for inpatient and outpatient level-of-care decisions.
- Proprietary criteria: Some large insurers develop their own internal guidelines.
These criteria are applied to your clinical information to determine whether your condition meets the criteria for the level of care you are receiving. If your condition has stabilized to the point that the criteria no longer support inpatient care, the insurer may deny continued coverage — even if your physician believes you are not ready for discharge.
Can a Concurrent Review Denial Be Overturned?
Yes. Concurrent review denials are successfully appealed regularly. Grounds for overturning a denial include:
- The criteria applied were inappropriate for your diagnosis
- The reviewer failed to consider all relevant clinical information
- Your condition deteriorated or new complications arose after the initial denial
- The insurer failed to follow required notice timelines
- The denial was based on a care level comparison that does not apply in your geographic area (e.g., a skilled nursing facility was not actually available)
Your physician's written statement explaining why continued inpatient care is medically necessary is often the most powerful piece of evidence in a concurrent review appeal.
How Is Concurrent Review Different From Prior Authorization?
- Prior authorization (also called preauthorization or precertification) is required before elective or scheduled services begin.
- Concurrent review occurs during ongoing care, while you are actively receiving treatment.
- Retrospective review happens after treatment is complete and evaluates whether care already delivered was covered.
Concurrent review carries more urgency because a denial can affect care that is happening right now. Appeals timelines are compressed, and the stakes — including potential patient harm from premature discharge — are higher.
Fight Back With ClaimBack
If your insurer is trying to cut off coverage during an ongoing hospitalization or treatment, you have rights and time is critical. ClaimBack helps you build an urgent, evidence-based appeal to challenge concurrent review denials quickly and effectively.
Start your appeal at https://claimback.app/appeal.
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