Providers serving affected plans in Illinois, Nevada, Kentucky and New Jersey will lose access to pre-determination reviews. Clinical discussions after a denial remain available, with scheduling instructions provided in the denial letter.
By Adam Vibe Gunton, Behavioral Health Partners
October 19, 2026
Behavioral health providers working with four health plans will no longer be able to request a peer-to-peer review before an authorization decision beginning October 19, 2026. The change affects requests covered by notices from Meridian Medicaid Plan, SilverSummit Healthplan, WellCare of Kentucky and Fidelis Care in New Jersey.
All four plans say providers can still request a peer-to-peer discussion after an authorization is denied. Their notices also state that the overall medical-necessity review process and notification timelines remain unchanged.
For treatment organizations, the change requires attention to what happens between an initial submission and a denial. Teams accustomed to arranging a clinical discussion before a decision will need to adjust that practice, then act on the denial letter’s instructions without losing track of separate appeal deadlines.
What the health plans announced
The four announcements describe the same adjustment: behavioral health advisor reviews will follow the plans’ existing physical health process. Pre-determination peer-to-peer reviews will end, while post-determination opportunities will remain available.
| Health plan and official notice | State | Notice date |
|---|---|---|
| Meridian Medicaid Plan | Illinois | October 7, 2026 |
| SilverSummit Healthplan | Nevada | September 18, 2026 |
| WellCare of Kentucky | Kentucky | September 22, 2026 |
| Fidelis Care | New Jersey | Not displayed |
Each notice identifies October 19 as the effective date. Providers should confirm that the announcement applies to the member’s specific product before changing how an individual request is handled.
The plans describe the adjustment as a way to streamline reviews and allow physicians to spend more time on patient care when a consultation is unnecessary for approval. The announcements do not provide outcome data showing whether the change will shorten authorization times or affect denial rates.
What happens after an authorization is denied
A peer-to-peer review allows the treating clinician to discuss a case with the plan’s clinical reviewer. Under the announced process, providers seeking that discussion after a behavioral health denial should use the scheduling instructions in the denial letter.
That makes the complete determination letter an important working document for utilization-review staff and the treating clinician. The team needs to understand the reason for the denial, what services and dates are affected, how to request the discussion and when the request is due.
The October notices do not establish a common request deadline across the four plans. Meridian’s January 2026 provider manual offers a more specific reference for its providers. On page 49, the manual states that a post-denial peer-to-peer request must be submitted within 10 calendar days of the initial denial notification. It also says Meridian will work with the treating physician to schedule the discussion within three business days of receiving the request and provide written notice of the decision within 24 hours of the review.
The manual predates the October announcement and includes broader language about discussions during the review process. Providers should read it alongside the new notice and the current denial letter, asking Meridian to resolve any conflicting instructions promptly. Its published deadlines should not be applied to SilverSummit, WellCare of Kentucky or Fidelis Care.
For cases already pending on October 19, including discussions previously scheduled, staff should confirm with the plan how the transition applies to that particular request.
Protect the member’s appeal rights
A peer-to-peer discussion and a formal appeal serve different functions. The discussion gives a clinician an opportunity to address the plan’s reasoning. An appeal asks the plan to review an adverse benefit determination through its established appeal process.
The October announcements do not say that requesting a peer-to-peer discussion extends the time allowed for an appeal. Providers should therefore record and manage both deadlines independently.
For Medicaid managed care appeals governed by the federal rules on filing a member appeal, the enrollee has 60 calendar days from the date on the adverse benefit determination notice to request a plan appeal. Providers appealing on a member’s behalf must meet the applicable representation and consent requirements. That member appeal is separate from a provider’s claim-payment dispute.
Urgent cases require additional attention. The federal standard for expedited Medicaid appeals addresses situations in which the time needed for a standard appeal could seriously jeopardize the member’s life, physical or mental health, or ability to attain, maintain or regain maximum function.
For those expedited appeals, federal resolution requirements limit the state-established timeframe to no more than 72 hours after receipt, subject to permitted extensions. The decision must still be made as quickly as the member’s health condition requires. A shorter state or plan timeframe may apply.
When a denial concerns the reduction, suspension or termination of previously authorized treatment, staff should also examine the rules for continuing Medicaid benefits during an appeal. Those protections have specific eligibility conditions and time limits. They do not automatically extend to a newly requested service, and a peer-to-peer request alone does not secure continued benefits. Providers acting as a member’s representative cannot request that continuation on the member’s behalf under these provisions.
These are Medicaid managed care protections for the appeals they govern. Medicare, integrated-plan and commercial-product procedures require separate review.
Where treatment centers should focus
The most useful response is a review of the actual cases and staff responsibilities affected by the change. Utilization-review teams should confirm who receives determination letters, who routes clinical denials to the treating professional and who tracks the next deadline when the usual employee is unavailable.
Before a post-denial discussion, the clinician should have the original submission, the plan’s stated rationale and the records relevant to that rationale. If the decision changes, staff should obtain the written determination and confirm the authorized services and dates before updating the case as approved.
Admissions and care-coordination teams also need accurate information. A review that has been requested or scheduled is still a pending review. Patients and families should receive a clear explanation of the current decision, the next step and who is responsible for following up.
Meridian directs general questions about its announcement to its Provider Engagement team at ILProviderRelations@mhplan.com. Individual review requests should follow the channel identified in the denial letter.
For treatment-center leadership, the immediate question is whether the team can respond when the next denial arrives. The revised process needs to be clear enough that staff can arrange the appropriate clinical review, preserve appeal options and keep the patient’s care team informed without avoidable delay.
Written and reviewed by Adam Vibe Gunton, Founder and Managing Partner of Behavioral Health Partners.
Adam Vibe Gunton is an addiction recovery expert, entrepreneur, marketer, brand strategist, and speaker dedicated to advancing the behavioral health industry. As Founder and Managing Partner of Behavioral Health Partners, he has worked across treatment-center development, operations, branding, PR, SEO, advertising, and growth strategy. Combining professional experience with his own lived experience in recovery, Adam brings a unique perspective on how treatment organizations can build trusted brands, reach more people, and create a greater impact.
Last updated October 20, 2026
