How to set up utilization review for an IOP or PHP

Every IOP and PHP day a plan pays for has to be authorized and supported by the chart. When UR slips, the program finds out weeks later as a denied claim for days it already delivered. The workflow below is the one we wrote into the Continued Stay and Utilization Review Policy we give clients in our IOP / PHP Program Launch, and the one our EHR for programs runs.

Who does what

Role	UR duties	Notes
UR lead (coordinator)	Keeps the authorization log, checks it every business day, builds each review packet, submits reviews, schedules peer-to-peers, records outcomes, tells counselors and billing	Doesn't need to be a clinician, but must know each plan's process. The clinical words come from the counselor.
Intake coordinator	Verifies benefits and who manages behavioral health, starts the first authorization, hands the case to UR with the screen, records and a clinical contact	Often the same person as the UR lead in a small program.
Primary counselor	Writes the continued-stay clinical note within 1 business day of being asked; takes peer-to-peer calls for their clients	Never copies the last review forward.
Clinical director	Reviews every request before it goes, decides on appeals, audits the log monthly	Owns step-down decisions when criteria aren't met.
Medical director	Takes peer-to-peers that need a physician, especially for medical or psychiatric complexity	When the plan's reviewer is a physician, a physician-to-physician call is often the better conversation.
Billing	Bills only authorized, documented days at the authorized level; reports mismatches to UR	Authorization number on every claim that needs one.

UR never overrides clinical judgment about safety. If a client no longer meets criteria for their level, step them down even if days remain on the authorization; if they need more care, refer up even if the plan hasn't approved it yet.

Find out who reviews each plan

The plan on the card often isn't the company that authorizes behavioral health. UnitedHealthcare's behavioral network is run by Optum and Cigna's by Evernorth, and other plans hand behavioral health to managers like Carelon or Magellan, or to a different company for one employer group. For each payer, record the reviewing company, how it takes reviews (portal, fax, phone), its criteria (ASAM for substance use in many plans; MCG, InterQual, LOCUS or its own guidelines for mental health), and the contract's submission timeline. Our sister product's guide to behavioral health carve-outs explains how to tell, and the prior authorization guide covers what to ask on the first call.

The authorization log

One row per client per authorization, checked every business day. If it lives in a spreadsheet, it lapses the week the UR lead is out; put it in the EHR on each chart.

Field	Example (made up)
Chart number	0142 (never the client's name in a shared log)
Payer and reviewing company	Commercial plan; behavioral health managed by a separate company
Level and billing code	IOP, H0015
Authorization number	From the approval letter or portal
Start and end dates	Mon Nov 2 to Fri Nov 13
Days or units approved, and used	6 approved, 4 used
Review starts	5 days before the end date: Sun Nov 8, so Mon Nov 9
Status and next step	Packet started; note due from counselor Tue

Watch the "used" column as closely as the end date. An authorization for 6 IOP days can run out before its end date if the client attends more often than planned.

The first authorization

1. Intake verifies benefits for the level of care: coverage, cost-sharing, whether prior authorization is required and who gives it. Record the call reference number and the representative's name. Our VOB checklist lists every question.
2. The clinician completes enough of the assessment to support the request: diagnosis, the ASAM dimensions (substance use) or the plan's criteria (mental health), risk, and why a lower level won't do.
3. UR submits the request before the first day whenever the plan requires prior authorization, and logs the approval or the pending reference.
4. If the program isn't in network yet, ask for a single case agreement for that client at a rate agreed in writing before admission, and get the authorization in writing too.

The full intake sequence is in our guide to the IOP admissions process.

Concurrent reviews: timing

Work backward from the authorization's end date. A made-up IOP authorization ending Friday, November 13:

When	Step	Who
Mon Nov 9 (5 days out)	Start the packet: current assessment, treatment plan and latest review, recent group and individual notes, attendance (hours attended against scheduled), risk screens, medications, drug screen results for substance use	UR lead
Tue Nov 10	Counselor writes the continued-stay clinical note (within 1 business day of being asked)	Primary counselor
Wed Nov 11 (2 business days out)	Clinical director reviews; UR submits the review	Clinical director, UR lead
Thu Nov 12	Reviewer questions or a peer-to-peer request; take it the same day	Counselor or medical director
On the decision	Log days approved, new dates, reference number and the reviewer's name; tell the counselor and billing	UR lead

Five days is our default lead time; Cima EHR lets a program set anywhere from 1 to 14 days, and some contracts require earlier submission. Also start a review on any level change (PHP to IOP needs its own authorization) and after any event that changes the picture: a return to use, a crisis, a hospital stay.

What the continued-stay note must show

• Progress and barriers in each dimension, with specific, dated examples from this client's chart. For substance use, address all six ASAM dimensions in the edition your payer uses.
• Attendance: days and hours attended against scheduled, and the reason for each absence.
• Current risk: suicide, violence, relapse or overdose, and medical, with what the plan does about each.
• Why this level and not a lower one: what would likely happen if the client stepped down now.
• The step-down plan: the next level, the signs that will show readiness, and a target date.
• The request: a number of days with start and end dates, and the services the client will receive.
• Changes to the treatment plan since the last review.

The counselor writes it in their own words from this client's chart. Reviewers compare reviews, and repeated text reads as unsupported. Texas requires the same reasoning in the chart itself: each treatment plan review must evaluate progress on every goal and justify the continued length of stay (26 TAC 564.804(i)), and a licensed facility's utilization review must ensure appropriate placement, adequate services and length of stay (564.504). Cima EHR prompts the review 5 days before the last authorized day and asks for exactly these items.

Peer-to-peer reviews

When a reviewer questions a request, ask for a peer-to-peer within the plan's window (often 24 to 48 hours; check each contract). Who takes it matters more than anything else: the clinician who knows the client best, or the medical director.

Denials and appeals

1. Read the denial letter the day it arrives: the reason, the criteria used and the appeal deadline. Log all three.
2. The clinical director decides with the counselor whether to appeal, and whether it's urgent (expedited) because a delay could harm the client.
3. Write the appeal from the chart: dated examples for each criterion the plan said wasn't met, not general statements about the program.
4. When internal appeals are exhausted, request an external review where the plan or state law allows it. For Texas state-regulated plans that's an independent review organization; the Texas Department of Insurance explains the IRO process.
5. Tell the client about the denial, their own appeal rights and their options: step down, pay privately, or continue while the appeal is decided, with the cost explained in writing.
6. Track every denial and its outcome. A pattern by plan, counselor or dimension is a training problem you can fix.

The rules behind the timelines

• Texas state-regulated plans (fully insured plans and HMOs): utilization review is governed by Texas Insurance Code chapter 4201, which sets when notice of an adverse determination is due, requires the reviewer to give the provider an opportunity to discuss the treatment before an adverse determination (§4201.206), and sets appeal rights. Independent review organizations are certified under chapter 4202.
• Self-funded employer plans follow federal ERISA claims rules instead (29 CFR 2560.503-1), including the rules for urgent care and for extending a course of treatment already approved. A request to extend urgent care made at least 24 hours before the approval ends must be decided within 24 hours, which is one more reason to submit early.
• Medicaid managed care plans follow their HHSC contract and federal Medicaid rules; ask each plan for its review timelines.

Ask on the first call which kind of plan the client has. The card often doesn't say whether the employer self-funds.

UR metrics

Measure	How it's calculated	Starting target
Authorization denials	Days denied ÷ days requested, by plan	Under 5%
Lapsed authorizations	Client-days delivered with no active authorization where one was required	0
Reviews on time	Reviews submitted 2 or more business days before the end date ÷ all reviews	95% or higher
Peer-to-peer outcomes	Peer-to-peers that kept or restored the requested days ÷ all peer-to-peers	Track the trend by plan
Appeal outcomes	Appeals won ÷ appeals filed, and dollars recovered	Track the trend
Billing match	Days billed that match an authorization and a signed note ÷ days billed	100%

The denial target comes from the performance improvement plan in our program kit; set yours from your own first quarter. Review the numbers monthly and in the quarterly quality review.

How much UR work to expect

UR workload is census times review frequency. Do the math for your own plans. A made-up example: 20 clients whose plans review every 7 days on average means about 20 reviews a week, or 4 a business day. If each review takes the UR lead about 45 minutes (packet, submission, logging; time your own), plus the counselor's note, that's about 3 hours a day of UR coordination before peer-to-peers and appeals. That's why a small program can combine UR with intake, and why it can't be squeezed into the last hour of a counselor's day. When we build a program's staffing plan, we size the intake and UR role from the expected census and the program's own payer mix.

Questions

What does a utilization review coordinator do in an IOP or PHP?

Keeps the authorization log, starts each concurrent review on time, builds the packet, submits it, schedules and preps peer-to-peers, records outcomes, and makes sure billing only bills authorized, documented days. The clinical content comes from the counselor and clinical director.

What's the difference between prior authorization and concurrent review?

Prior authorization approves the level of care before treatment starts. Concurrent review approves more days while the client is in treatment, based on progress, risk and why the level is still needed.

How early should a concurrent review be submitted?

We start the packet at least 5 days before the authorization ends and submit at least 2 business days before, or earlier if the contract says so. For urgent care under self-funded plans, a request made at least 24 hours before the approval ends must be decided within 24 hours.

What is a peer-to-peer review?

A call between your clinician and the plan's reviewing clinician to discuss a request the reviewer is questioning or has denied. For Texas state-regulated plans, Insurance Code §4201.206 requires the reviewer to offer the provider a chance to discuss the treatment before an adverse determination.

What should we do when days are denied?

Log the reason and deadline the same day, decide on an appeal with the clinical director, appeal with dated chart evidence, request external review when internal appeals are exhausted, and tell the client their options in writing. Never keep billing denied days.

Want a one-off look first? A chart audit reads 10 charts the way a payer auditor would for $750 per 10 charts. Or book a free 30-minute call.

Cima Consulting isn't a law firm. Plan contracts, state law and federal rules decide review timelines and appeal rights; we don't guarantee any authorization or appeal outcome.

Sources

• Texas Insurance Code chapter 4201, Utilization Review Agents: statutes.capitol.texas.gov
• Texas Department of Insurance, Independent Review Organization FAQ: tdi.texas.gov
• 29 CFR 2560.503-1, ERISA claims procedure: eCFR
• 26 TAC 564.804, treatment plan reviews (Cornell LII): law.cornell.edu; 26 TAC 564.504 (Cornell LII): law.cornell.edu
• ASAM, The ASAM Criteria: asam.org