Peer-to-Peer Review: Getting Your Doctor to Talk to Theirs

A peer-to-peer review is a direct conversation between your treating physician and the insurance company's medical director. It's one of the most effective tools to overturn a medical necessity denial before filing a formal appeal.

What Is a Peer-to-Peer Review?

A peer-to-peer (P2P) review is a phone call between your doctor and the insurance company's medical reviewer. Your doctor can:

  • Explain the clinical rationale for the treatment
  • Provide additional context not in the written records
  • Address the insurer's specific concerns
  • Present new evidence or updated clinical guidelines

When to Request P2P

Request a P2P review when:

  • The denial is based on medical necessity
  • Your doctor strongly supports the treatment
  • Additional context could change the decision
  • You want to expedite the process before filing a written appeal

Tips for a Successful P2P Review

For the Patient

  1. Ask your doctor to schedule the P2P call promptly
  2. Provide your doctor with the denial letter and specific criteria used
  3. Prepare a summary of your treatment history
  4. Follow up with your doctor after the call

For the Physician

  1. Review the insurer's clinical criteria before the call
  2. Be prepared to cite specific clinical guidelines
  3. Explain why alternatives are insufficient
  4. Document step therapy failures
  5. Note the reviewer's name, credential, and any commitments made
  6. Take notes during the call
  7. Follow up in writing after the call

What to Expect

  • The call typically lasts 15-30 minutes
  • The insurer's reviewer may or may not reverse the denial during the call
  • If the decision isn't reversed, you'll still have the right to file a formal written appeal
  • The P2P conversation becomes part of your appeal record

Need Help Writing Your Appeal?

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Frequently Asked Questions

Can I participate in the peer-to-peer review call?

Typically, only the physicians participate in a peer-to-peer review call. However, you can prepare your doctor by providing the denial letter, your medical history summary, and the specific clinical criteria the insurer used to deny your claim.

What if the peer-to-peer review doesn't work?

If the peer-to-peer review doesn't result in a reversal, you still have the right to file a formal written appeal. The P2P conversation may actually strengthen your written appeal by identifying the specific objections you need to address.

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