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Concurrent review is the stage of healthcare utilization review and utilization management conducted during an active inpatient hospitalization, post-acute admission, or ongoing course of treatment to verify continued medical necessity, appropriate level of care, and discharge readiness. It contrasts directly with prospective review (prior authorization and precertification performed before care is delivered) and retrospective review (post-service claim review performed after discharge).
What Is Concurrent Review in Healthcare?
During an inpatient stay, hospital Utilization Review (UR) nurses and payer utilization management reviewers evaluate contemporaneous clinical documentation—daily progress notes, vital signs, IV therapies, laboratory values, and functional status—against evidence-based criteria sets such as Optum InterQual Criteria or MCG Care Guidelines (see MCG vs. InterQual). Under 42 CFR § 482.30(d) (CMS Hospital Conditions of Participation for Utilization Review) and 29 CFR § 2560.503-1(f)(2)(ii) (ERISA Concurrent Care Decisions), concurrent review governs continued-stay authorizations and enforces the federal 24-hour urgent extension turnaround rule.
Prospective vs. Concurrent vs. Retrospective Review Timelines
Under 29 CFR § 2560.503-1, urgent concurrent care extension requests submitted at least 24 hours before the expiration of the approved period must be decided within 24 hours; initial urgent pre-service claims within 72 hours; standard pre-service claims within 15 days (or 7 calendar days for payers subject to CMS-0057-F); and retrospective post-service claims within 30 days.
Primary Sources
- U.S. Department of Labor, Employee Benefits Security Administration (EBSA): 29 CFR § 2560.503-1 (Claims Procedure — Concurrent Care, Urgent Care, Pre-Service, and Post-Service Claims).
- Centers for Medicare & Medicaid Services (CMS): 42 CFR § 482.30 (Condition of Participation: Utilization Review) and CMS-0057-F (42 CFR § 422.568 Interoperability and Prior Authorization Final Rule).
