The reviewer asked what changed since the last review. Did your coordinator have an answer?

The residential day starts normally. At 10:40 the utilization review coordinator gets the reviewer on the line for a patient whose last authorized day is Thursday. The reviewer asks what has changed since the last review. The coordinator knows the patient had a rough weekend, but the nursing note from Saturday is not in the packet, the therapist's Monday note is unsigned, and the treatment plan still reads the way it did at admission. The coordinator says the patient is "still working on coping skills." The reviewer approves two days and asks for a discharge plan. The program spends the next week arguing for days it probably could have had on the first call. This post is about the twenty minutes before that call.

What the reviewer is actually deciding

A concurrent review is utilization review performed while the patient is still in treatment. The payer's reviewer is applying medical necessity criteria, which may be the ASAM Criteria, the payer's own criteria, or a combination, depending on the plan and contract. Confirm which criteria set and which edition each payer uses, because the questions on the call follow from it.

Whatever the criteria, the reviewer is generally trying to answer three questions:

1. Does the patient still meet criteria for this level of care, or could they be treated safely at a lower one?
2. Is treatment producing change, or is the patient in the same place as at the last review with the same plan?
3. Is there a realistic plan to step down or discharge, and what is in the way of it?

Every one of those questions is answered with specifics. A reviewer cannot approve days against an impression. They can approve days against "on Saturday night she reported cravings at a level she rated as the highest since admission, left the group room twice, and nursing documented a request for PRN medication." That sentence has a date, a source and an observation. "Still struggling" has none of those.

What should be in front of the coordinator before the call

Build a one-page prep sheet for every review, pulled from the chart, not from a hallway conversation. The exact contents will vary by payer and level of care, but most calls need these:

1. The authorization facts

• Authorization or reference number, level of care authorized, start date and last covered date.
• Days authorized versus days used, counted from the census rather than from memory.
• Any conditions the reviewer attached last time, such as a request for a family session or an updated discharge plan.

If the last reviewer asked for something and the coordinator does not know it was asked, the call opens on the back foot. Read the notes from the previous call first.

2. The current clinical picture, by dimension

If the payer uses ASAM, organize the clinical picture by the six dimensions, with the date each was last assessed. Reviewers often walk the dimensions in order, and a coordinator who can answer each one with a dated observation keeps the call moving. If a dimension has not been reassessed since admission, that is worth knowing before the reviewer notices it.

3. What changed since the last review

This is the question that decides most calls, and it is the one coordinators are least prepared for. List the changes with dates: symptoms, medication adjustments, incidents, safety concerns, family contact, participation, outcome scores. Include changes in both directions. Progress supports a plan to step down on a schedule; a setback with documented specifics supports continued stay. No change at all, with no change to the plan, is the hardest position to defend.

4. Recent events, with sources

• Relevant entries from progress notes, nursing notes and medication administration since the last review.
• Incidents, safety round observations or elevated precautions, with dates.
• Attendance and participation in programming, including groups missed and why.
• Recent outcome measure scores against baseline, where you collect them.

Each item should point back to a signed record. If the coordinator is quoting a note that is not signed yet, the reviewer may later find the record does not say what the call said.

5. The treatment plan and what the team is doing differently

Reviewers ask what the plan is for the next authorized period, not the plan written at admission. Have the current goals, any revisions since the last review, and the specific interventions planned for the days being requested. If the plan has not changed and the patient has not progressed, expect the reviewer to ask why the same plan should be paid for again.

6. The discharge plan and its barriers

"Discharge plan TBD" is a common reason a call ends with fewer days than requested. Have the target level of care after this one, the anticipated date, what has been arranged so far, and the specific barriers: no step-down bed available, housing not secured, an outpatient intake not yet scheduled. Barriers that are named and being worked on read very differently from an empty field.

Why the denial traces back to the call

When a continued-stay request is denied or cut short, the instinct is to blame the payer's criteria. Sometimes that is fair. But when you pull the chart afterward, the facts that would have supported more days are often already there. They were just not on the call. A few patterns repeat.

The coordinator summarized instead of citing

Summaries flatten a record. "Doing better" can mean the patient slept through the night once or that cravings have resolved. The reviewer hears the second. Train coordinators to answer with the observation and its date, then the interpretation.

The documentation was not finished

The therapist saw the patient yesterday and the note is not signed. The coordinator either leaves it out or describes it secondhand. Either way the call is weaker, and if the payer later requests records, the call and the chart may not match. Documentation timeliness is usually discussed as a billing problem. It is also a utilization review problem, because the review happens on the documentation that exists that morning.

Nobody owned the discharge plan

Clinical staff assume case management has it; case management is waiting on the clinical team's recommendation. The coordinator finds out on the call. Assign the discharge plan an owner at admission and have that owner update it before every review.

The previous reviewer's request was never answered

Last week's reviewer approved days and asked for a medication evaluation. It happened, but it is buried in a psychiatric note the coordinator did not read. This week's reviewer sees an unanswered request. Every call's requests should become tasks with an owner and a due date before the next review.

Building the prep into the week

None of this needs a new department. It needs a routine. One that works for many programs:

1. Keep a review calendar driven by last covered dates, so every upcoming review is visible at least a day or two out.
2. The day before each review, the coordinator pulls the prep sheet and lists what is missing: unsigned notes, a dimension not reassessed, a blank discharge plan.
3. Missing items go to their owners that day, not on the morning of the call. Clinicians sign the note; case management updates the discharge plan.
4. A short huddle with the primary clinician confirms what has changed and what the team is asking for, and why.
5. The coordinator makes the call with the sheet in front of them and the chart open.

For a hypothetical 30-bed residential program with several reviews a day, the prep step is where the time goes. That is the point: time spent before the call is cheaper than a peer-to-peer, an appeal, or days delivered without authorization.

After the call, write it down

The record of the call is as important as the call. Document the date and time, the reviewer's name, the reference number, the outcome, the number of days approved and the new last covered date, the next review date, and anything the reviewer requested. If the request was denied or partially approved, record what the reviewer said was missing and the options offered, such as a peer-to-peer review or an appeal. Deadlines and procedures for those vary by payer, plan and state, so confirm them against the payer contract and the applicable rules rather than relying on what was said on the phone.

That record serves twice: it sets up the next review, and if the episode is ever audited, it shows what the payer was told and when. Our posts on prior authorization and audit packets cover the authorization clock and the audit side in more detail.

Where the record itself can help

The prep sheet is only as good as the record it comes from. When census, notes, medications and the plan live in separate places, the coordinator becomes the person stitching them together every morning. In Unisona Health, prior authorizations are tracked as days authorized against days used from the live census, and the ASAM criteria workflow records six-dimension scoring on your own form and ties the treatment plan to those dimensions, while the placement decision stays with your clinicians. Whatever system you use, the test is the same: can the coordinator answer "what changed since the last review" from the chart, with dates, before the reviewer picks up?

Frequently asked questions