Concurrent Review in Behavioral Health: How to Hold the Authorization

A program rarely loses a residential or PHP authorization at admission. It loses it on day six, when the extension request goes in late, the chart answers the wrong question, and the plan turns an approved stay into a denied one. Concurrent review is where behavioral health revenue leaks, and it is the stage of utilization review with the tightest clocks in law. This guide sets out those clocks for Oregon and Washington programs, the criteria each major carrier scores against, and the continued stay packet that holds the authorization. For the admission stage, start with our guide to behavioral health prior authorization.

Why do programs lose authorizations at concurrent review rather than at admission?

Federal claims rules treat a continued stay as a concurrent care decision: the plan has approved a course of treatment over a period of time or a number of treatments, and now the program asks to extend it or the plan moves to cut it short. In our billing work, the last covered day is on nobody's calendar, so the extension request lands after the authorization has lapsed and the 24 hour decision clock never starts. The clinical update says the patient is engaged and improving, which a reviewer reads as readiness for a lower level of care. Nobody has asked which criteria set the plan scores. Every one of those is cheaper to fix than to appeal.

What clocks does federal law put on a continued stay decision?

29 CFR 2560.503-1 is the Department of Labor claims procedure rule for employer plans under ERISA. 45 CFR 147.136 extends it to non grandfathered group plans and individual coverage and adds protections of its own; the Department's claims procedure FAQs explain the concurrent care rules.

The 24 hour clock is the one to build around, and it only starts if the request is timely. A request that lands 20 hours before the last covered day is decided on the 72 hour clock, which is three more days of unauthorized care at a residential per diem.

What do Oregon and Washington add for the plans they regulate?

State insurance law reaches the plans the state regulates. A self funded employer plan usually follows the federal rules alone, so find out which kind of plan you have at verification. For everything else, both states add clocks and criteria rules a reviewer cannot wave off.

Oregon

• The criteria are prescribed. ORS 743A.168(5) requires every behavioral health review to rest solely on current generally accepted standards of care, with placement decided under the most recent criteria of the nonprofit professional association for the specialty. The insurer must authorize the level consistent with the insured's score and, on a disagreement, give the provider the full details of its scoring.
• Two business days, and a phone that answers the same day. ORS 743B.423 requires a decision on a nonemergency request within two business days, qualified personnel available for same day telephone responses on certification of continued length of stay, and written denials that state the specific reason based on peer reviewed literature.
• Appeals move at clinical speed. ORS 743B.250 requires an expedited internal appeal that accommodates clinical urgency and the opportunity to receive continued coverage of an approved and ongoing course of treatment. ORS 743B.252 requires expedited external review when the denial concerns a continued stay, and under ORS 743B.256 the independent reviewer decides by the third day.

Washington

• No review for the first two business days of residential SUD care. RCW 48.43.761 requires a plan to cover no less than two business days of inpatient or residential SUD treatment, and three days of withdrawal management, before conducting utilization review, with no prior authorization as a condition of payment for that period. The agency must notify the plan within 24 hours of admission and deliver its initial assessment and treatment plan within two business days, or three for withdrawal management.
• Fourteen days, then seven. For plans issued or renewed on or after January 1, 2025, the authorization that follows the initial review may not be shorter than 14 days from admission and each later one must run at least seven days. The plan may not consider length of stay in deciding whether to continue care, and when the approved plan is a transfer it pays the current agency until the seamless transfer is complete.
• The criteria are the ASAM Criteria. Review under RCW 48.43.761 uses the standard set of criteria established under RCW 41.05.528, and the agency must document the need for continuing care and the justification for the level of care in the medical record. RCW 48.43.764, amended in 2025, names the ASAM Criteria and says carriers and Medicaid managed care organizations shall begin using the Fourth Edition no later than January 1, 2028 unless the Health Care Authority and the Insurance Commissioner jointly decide otherwise.
• Twenty four hours for urgent concurrent review, and a notice that names the next review date. WAC 284-43-2000 requires written clinical review criteria available on request to participating providers, urgent concurrent inpatient review decisions no later than 24 hours, and a notification that, as appropriate to the type of request, states the number of extended days, the next anticipated review point and the new total approved.

Which criteria will the reviewer score, carrier by carrier?

Every row below comes from the carrier's own published page, opened in October 2026; our commercial payer map for Oregon and Washington covers the rest of the market. Where a carrier publishes nothing on its public pages, as Regence's pre authorization page sits behind its provider portal, Oregon and Washington law entitle a contracted provider to the criteria on request.

What goes in a continued stay request that gets approved?

The reviewer is answering one question: does the record show the patient still meets continued service criteria at this level and would not be as safe and effective one level down. Oregon writes that test into law, requiring treatment at the least intensive and least restrictive level of care that is safe and most effective. Moda says it in a carrier's words: residential is approved when the next lower level is appropriate but not reasonably available. Washington requires the agency to document the need for continuing care and the justification for the level of care in the medical record. The packet that holds the authorization answers that question directly, in the criteria language, with dates, which starts with clinical documentation built on ASAM criteria program design.

• Lead with the scores. Put the dimensional ratings or LOCUS score, with the assessment date, in the first lines.
• Write the step down argument out loud. Name the lower level, say why it is not yet safe or effective for this patient this week, and cite the risk that drives the answer. Improvement without that sentence reads as readiness to discharge.
• Make the discharge plan real. A step down date, the receiving program, and the barrier that blocks it this week. Moda will not authorize the higher level where the facility fails to engage in reasonable discharge planning.

How do you run the review calendar so nothing lapses?

• Put the last covered day on a shared calendar. Submit the extension at least 24 hours before it and record the time of submission. That timestamp starts the federal 24 hour clock and wins the argument if the plan decides late.
• Notify at admission, every time. Washington SUD programs must tell the plan within 24 hours and send the assessment and treatment plan within two business days. Calendar the next review the day an approval notice names it.
• Request the peer to peer inside the window, and ask for the reviewer's criteria and scoring at the same time. In Oregon the insurer must provide the full details of its scoring when the parties disagree about the level of care, and in both states a contracted provider is entitled to the criteria on request.
• Keep treating while you appeal where the rule allows it. For non grandfathered group coverage, 45 CFR 147.136 requires coverage to continue pending the appeal of a reduction or termination of an ongoing course of treatment, an individual policy cannot reduce or end an ongoing course of treatment without advance notice, and Oregon law gives the enrollee the opportunity to receive continued coverage. Ask for the expedited internal appeal, and in Oregon the expedited external review for a continued stay denial, decided by the third day.
• Count the denial. A concurrent review denial is a denial like any other. Log it with your claim denials; the pattern by carrier tells you whose criteria your charts are failing. Our guide to stopping behavioral health claim denials covers the denial log, and our payer contracting guide covers the contract terms that set review frequency in the first place.

Frequently asked questions

Can a Washington plan require prior authorization for residential substance use disorder treatment?

Not for the first two business days. RCW 48.43.761 requires a plan to cover at least two business days of inpatient or residential SUD treatment, and three days of withdrawal management, before conducting utilization review, with no prior authorization as a condition of payment for that period. For plans issued or renewed on or after January 1, 2025, the first authorization after that review must run at least 14 days from admission and each later one at least seven days.

How fast must a plan decide a request to extend a residential stay?

Under 29 CFR 2560.503-1, a request to extend an urgent ongoing course of treatment made at least 24 hours before the approved period ends must be decided within 24 hours; a later request is an urgent care claim decided within 72 hours. Oregon adds a two business day limit on nonemergency determinations and same day telephone responses on continued length of stay under ORS 743B.423. Washington requires urgent concurrent inpatient review decisions no later than 24 hours under WAC 284-43-2000.

Does a continued stay denial mean the program stops being paid that day?

Usually not. Under 29 CFR 2560.503-1, cutting an approved course of treatment short is an adverse benefit determination that needs notice far enough in advance to allow an appeal, and under 45 CFR 147.136 a non grandfathered group plan must continue coverage pending the appeal, while an individual policy cannot reduce or end an ongoing course of treatment without advance notice. Oregon gives enrollees the opportunity to receive continued coverage of an approved and ongoing course of treatment, and for Washington SUD stays the plan pays the current agency until a seamless transfer to the approved lower level of care is complete.

Which criteria will the reviewer use?

Oregon requires behavioral health reviews to rest on generally accepted standards of care and the most recent placement criteria of the nonprofit professional association for the specialty. Washington requires SUD review to use the standard set of criteria under RCW 41.05.528, which RCW 48.43.764 identifies as the ASAM Criteria. Carrier pages opened in October 2026 show Aetna, Moda and Optum scoring SUD against the ASAM Criteria, Aetna and Optum using LOCUS for mental health, Evernorth using MCG, and Premera using InterQual.

Is the 2024 federal parity rule in effect?

Only in part. On May 15, 2025 the Departments of Labor, Health and Human Services and the Treasury said they will not enforce the portions of the 2024 MHPAEA final rule that are new relative to the 2013 rule until a final decision in the ERISA Industry Committee lawsuit plus 18 months. The statutory obligations of MHPAEA, as amended by the Consolidated Appropriations Act of 2021, continue to have effect, and plans may rely on the 2013 rule.

Hold the authorization, then make sure it pays

Concurrent review is where a clinical director and a biller have to read the same chart the same way. Our billing team has run treatment programs, so a continued stay request leaves our desk written in the reviewer's criteria with the clocks already on the calendar. If authorizations are lapsing, start with our free 90 day claims review: we read your concurrent review denials against the rules above and your contracts and show you what they are costing. Our behavioral health billing service and revenue cycle work keep the authorization and the payment in the same hands.