Today I’m going to briefly focus on the timely notification of an organization determination, and the new rules effective since the start of this year.
Here’s the scenario. A Medicare Advantage (MA) member is admitted. The hospital notifies the plan on time. And then – nothing. Days go by. The patient improves, goes home, and only then does the plan’s determination show up. Often, it’s a denial of the inpatient level of care.
Providers are seeing more of these late determinations on concurrent inpatient stays. And timing is not a technicality. When the decision arrives after discharge, the patient has lost the expedited appeal meant to protect them while they were still in the bed, and the hospital is chasing payment for care it already delivered.
So, what does the Centers for Medicare & Medicaid Services (CMS) actually require? The rules are clearer than the reality.
It’s all in 42 CFR Part 422, Subpart M. Section 422.566 says every MA organization must have a pair of procedures for timely organization determinations. Not one – two: a standard track and an expedited track for when waiting could seriously jeopardize the enrollee’s life, health, or ability to regain maximum function.
On the standard track, as of Jan. 1, services subject to prior authorization get seven calendar days. It used to be 14.
On the expedited track, section 422.572, the plan has 72 hours to decide and to notify the enrollee and the physician, whether it’s favorable or adverse. A plan can extend that, but it has to tell you, and it has to serve the patient.
Case managers and physician advisors, remember this. In the 2026 Final Rule – CMS-4208-F, published in April 2025 – CMS said plainly that for pre-service or concurrent review of inpatient services, the facts will often satisfy the medical exigency standard. Translation: CMS expects concurrent inpatient reviews to be expedited in most cases. The same rule confirmed that a decision made during the stay is an organization determination with full appeal rights, and it barred plans from reopening an approved admission, except for obvious error or fraud.
Now, the kicker: Section 422.572, paragraph (f). If the plan fails to give timely notice of an expedited determination, that failure itself constitutes an adverse organization determination, and it may be appealed. Silence is a denial. And a denial can be appealed.
Three things to do the morning after such a scenario arises.
- First, when you notify the plan of an admission, document the date and time, and request an expedited determination in writing. Start the clock on the record.
- Second, track the 72 hours. When it expires with no answer, treat it as what the regulation says it is – an adverse determination – and file the appeal. Don’t wait for the letter.
- Third, log every late determination and report the pattern to your CMS regional office. Timeliness is audited.
I’ll close with the patient. The patient who gets a denial in the mail two weeks after discharge is often the one with no caregiver, limited health literacy, and no capacity to fight it. A timely determination isn’t paperwork.
It’s a patient protection. Let’s hold the plans to it.
Regulatory References
42 C.F.R. § 422.566 — Responsibilities of the MA organization: standard and expedited procedures for organization determinations.
42 C.F.R. § 422.568(b) — Standard timeframe: 7 calendar days for services subject to prior authorization (effective January 1, 2026); 14 calendar days otherwise.
42 C.F.R. § 422.570 — Expediting certain organization determinations (medical exigency standard).
42 C.F.R. § 422.572(a), (b), (f) — Expedited determination within 72 hours; extension of up to 14 calendar days when in the enrollee’s interest; failure to provide timely notice is itself an adverse organization determination and may be appealed.
CMS-4208-F, Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, 90 Fed. Reg. 15910 (April 15, 2025) — concurrent-review decisions are organization determinations with appeal rights; approved inpatient admissions may be reopened only for obvious error or fraud; CMS expects expedited handling of most concurrent inpatient reviews.
