Aetna isn’t Cigna. Neither is Optum. We design the workflow for each.
Programs that treat every payer the same lose authorized days they should have kept. We analyze your actual payer mix, then design and operate a workflow per payer — PA rules, criteria emphasis, submission channels, review cadence, and the denial language that signals what to overturn.
Why per-payer
Five things every payer decides differently.
Each of these is independent. Your team is implicitly making a decision on all five every time it submits — usually based on tribal knowledge that lives in a few people’s heads.
Which criteria set applies
ASAM, LOCUS / CALOCUS, MCG, or a proprietary internal standard. Each weights different dimensions.
How often concurrent review happens
Every 3 days. Every 7. Every 14. Per payer, per product line, sometimes per plan.
What supporting documentation is expected
Daily notes only, or daily notes + treatment-plan updates, or full assessments, or specific scored measures.
Submission channel and turnaround
Provider portal, secure fax, phone, EDI. Each has its own queue, its own SLA, its own audit trail.
Reviewer weighting and denial language
Specific phrases overturn specific denial reasons. Knowing which language each payer's reviewers respond to is operational, not generic.
Appeal and reconsideration paths
First-level reconsideration windows, peer-to-peer availability, formal appeal timelines and forms — all payer-specific.
Methodology
How we build the workflow for each of your payers.
Three steps. Repeated for every high-leverage payer in your book.
Payer-mix analysis
We start with your actual book of business — claims volume, paid claims, denials, days at risk — sliced by payer. The output is a ranked list: which payers drive volume, which drive denials, where the workflow effort and revenue leakage concentrate. The top 3–5 payers get bespoke playbooks first.
Per-payer playbook design
For each top payer, we build a playbook covering: what admissions must capture, when UR submits, what documentation is included, which portal / channel is used, what review cadence to expect, what the typical denial language looks like, and what evidence overturns it.
Operationalize and keep current
The playbook isn't a PDF — it's wired into the workflow your team already uses. The AI evidence pipeline applies the right criteria per payer. The cadence tracker fires alerts on the right schedule. And we update the playbook quarterly (or in-flight) as payer rules change.
Inside a per-payer playbook
Operational. Specific. Owned by your team.
Every playbook we build is a concrete operating standard for one payer at one level of care. It replaces the unwritten knowledge with something a new UR nurse could pick up on day one.
- When prior auth is required (by patient plan, by LOC, by service)
- What admissions must capture at intake to make initial auth defensible
- Which criteria set this payer's reviewers actually weight (ASAM dimensions, LOCUS sub-scores, MCG indicators)
- Concurrent / continued-stay review cadence and submission window
- Submission channel (portal, fax, phone) with credentialed access pattern
- Documentation expectations per review (notes, assessments, treatment-plan updates, scored measures)
- Common denial language for this payer — and the evidence that overturns it
- Appeal / reconsideration windows and the contact path
- Routing — who on your team handles which step, with backups
Sample playbook
Aetna · Adult PHP (SUD)
Last updated
2026-05-19
Illustrative sample. Your playbooks reflect each payer’s current rules and your actual operating workflow.
Coverage
The payers we build for, today.
We’ve built playbooks for the major commercial payers most behavioral health programs see in their book. Medicaid coverage is per-state, per-MCO — added as engagements call for them.
Aetna
ASAM (SUD) · LOCUS (mental health)Behavioral-health carve-out variability by plan; concurrent review cadence often differs between commercial and Medicare Advantage product lines.
Cigna / Evernorth
ASAM · LOCUSContinued-stay reviews weight specific dimensions heavily; intensity-justification phrasing carries disproportionate impact in their reviewer scorecards.
BCBS (plan-by-plan)
ASAM · LOCUS · MCG (varies)Each BCBS plan operates as a distinct payer with its own criteria, portals, and review timing. Multi-state operators often run several BCBS workflows in parallel.
Optum / UHC
MCG (primary) · ASAM / LOCUSMCG-weighted reviewer scorecards; concurrent review cadence and continued-stay documentation expectations differ from competitors.
Magellan
ASAM · LOCUS / CALOCUSCarve-out behavioral health vendor for many commercial and Medicaid plans; their reviewer pool and documentation expectations are distinct from the parent payer.
State Medicaid MCOs
State-specific (ASAM common in SUD)Each state's Medicaid program — and each MCO administering it — operates as a distinct payer. Multi-state operators get a per-state workflow map.
Don’t see the regional or carve-out payer driving your denials? We build playbooks per engagement against the payers in your actual mix.
Playbooks don’t go stale.
Payers update PA requirements, criteria emphasis, and submission rules on their own schedules — sometimes quietly, often without a vendor notice. Out-of-date playbooks are how programs start losing authorized days again six months in.
- ·Quarterly payer-mix re-analysis is part of every engagement.
- ·In-flight payer-rule changes get pushed to your team as they're detected.
- ·Every denial outcome feeds back into the playbook — what overturned, what didn't.
Start here
Get your payer-mix analysis as part of the assessment.
The free Authorization Defense Assessment includes a payer-mix breakdown on your actual book — which payers drive volume, which drive denials, where the workflow effort and revenue leakage concentrate.