The Peer-to-Peer Review Process: A Complete Guide
Peer-to-peer review lets your doctor speak directly with the insurer's medical director about your case. It's one of the most effective — and underused — tools for overturning medical necessity denials.
How Peer-to-Peer Review Works
The Process
- Your doctor or their office requests a P2P with the insurer
- A phone call is scheduled (or sometimes happens ad hoc)
- Your treating doctor speaks with the insurer's reviewing physician
- They discuss clinical rationale for the requested treatment
- The insurer's doctor may overturn the denial during or shortly after the call
What They Discuss
- Patient's diagnosis and clinical presentation
- Treatment history and failed alternatives
- Why the requested treatment is medically necessary
- The insurer's clinical criteria and how the patient meets it
- Any questions the insurer's doctor has about the case
Preparation Guide for Your Doctor
Before the Call
- Review the denial letter and specific criteria cited
- Gather all relevant labs, imaging, and clinical notes
- Prepare a concise (3-5 minute) clinical summary
- Anticipate the insurer's objections
- Have peer-reviewed evidence ready to cite
During the Call
- Be professional and concise
- Lead with the clinical urgency
- Address each denial criterion specifically
- Mention failed alternative treatments
- Cite clinical guidelines from specialty societies
- Ask the reviewing doctor what additional information would be needed
After the Call
- Document the conversation details (reviewer name, date, discussion points)
- If the denial is upheld, ask for specific reasons
- Use the feedback to strengthen the formal written appeal
- Note any additional documentation requested
Effectiveness
- P2P reviews can resolve denials in a single phone call
- Particularly effective for prior authorization denials
- Many denials are overturned by simply providing clinical context the reviewer didn't have