What is Concurrent Review?

Concurrent review is the process by which a payor evaluates whether ABA services should continue to be authorized. It occurs at the end of each authorization period (typically every 6–12 months) and requires the provider to demonstrate that:

  • The client has made measurable progress toward treatment goals
  • ABA services remain medically necessary
  • The current intensity of services is appropriate for the client's current clinical presentation

    • Concurrent review is distinct from the initial authorization — it assumes services have been delivered and requires evidence of progress.

    What Triggers a More Intensive Concurrent Review

    Most concurrent reviews are routine. However, certain factors trigger more intensive scrutiny:

  • High intensity (30+ hours/week) — Payors scrutinize high-intensity authorizations more carefully
  • Long duration (2+ years of continuous ABA) — Payors may question whether ABA is still the appropriate level of care
  • Plateau in progress — If progress notes show no measurable improvement over the past 3–6 months
  • Prior denial history — Clients who have had previous authorization denials receive more scrutiny

    • What Payors Look for in Concurrent Review

    Evidence of Progress

    The most important element of a concurrent review submission is measurable evidence of progress. This means:

  • Graphs or data tables showing improvement in target behaviors from baseline to current
  • Mastered goals (goals that have been achieved and maintained)
  • Reduction in maladaptive behaviors from baseline levels

    • What doesn't count as progress: Narrative statements like "the client is doing well" or "the client has made significant progress." Progress must be demonstrated with objective data.

    Updated Medical Necessity Justification

    Even if the client has made progress, you must demonstrate that ABA services remain medically necessary. This means:

  • Identifying new treatment goals that require continued ABA intervention
  • Explaining why the client cannot maintain gains without continued services
  • Documenting any regression that occurred during breaks in service

    • Appropriate Intensity Justification

    If you are requesting the same intensity as the previous authorization period, justify why the same number of hours is still needed. If you are requesting a reduction in intensity (step-down), document the clinical rationale.

    Preparing for Concurrent Review: A Checklist

    4–6 weeks before authorization expiration:

  • Pull progress data for all active treatment goals
  • Identify goals that have been mastered
  • Identify goals that have not shown progress (and document why)
  • Update the treatment plan with new goals for mastered skills
  • Prepare progress graphs for each target behavior

    • 2–4 weeks before authorization expiration:

  • Submit concurrent review request with all required documentation
  • Include progress graphs and data tables
  • Include updated treatment plan
  • Include justification for continued medical necessity

    • 1–2 weeks before authorization expiration:

  • Follow up with the payor on the status of the concurrent review
  • If the review is not complete, request a temporary extension

    • Handling a Concurrent Review Denial

    If the payor denies the concurrent review request:

  • Request a peer-to-peer review. This is the most effective first step. A direct conversation between the treating BCBA and the payor's medical reviewer resolves many concurrent review denials.
  • File a formal appeal. If the peer-to-peer review is unsuccessful, file a formal appeal with updated documentation addressing the specific reason for denial.
  • Request a temporary authorization. While the appeal is pending, request a temporary authorization to continue services. Many payors will grant a 30-day temporary authorization to avoid a gap in care.
  • Involve the client's physician. A letter of medical necessity from the client's pediatrician or psychiatrist can strengthen a concurrent review appeal significantly.