Key points
- A peer-to-peer review is a call between your doctor and the plan's reviewing doctor about a denial. It is not an appeal.
- It is something to request before you file a formal appeal. We found no federal right to one and no federal deadline for it, so ask the plan the day you get the denial.
- Assume your appeal deadline keeps running. A call does not replace a written appeal unless the plan tells you otherwise in writing.
- Your doctor does the call. You make the request, give the office what it needs, and ask for the result in writing.
A peer-to-peer review is a phone call in which your doctor speaks with a doctor who works for your plan about a denial. It can be quick, and patient advocates often suggest asking for one before a formal appeal. It is not a right in the federal rules this site checked, and plans handle it differently. Ask the plan about it the day you get the denial, and keep your appeal deadline in view.
What this means
In an ordinary denial, a reviewer at the plan decides from the papers. A peer-to-peer call lets your doctor explain the case to a reviewing doctor directly. If the call goes well, the plan may reverse its decision. If it does not, you still have your appeal rights.
Be realistic about what you can expect:
- The Patient Advocate Foundation lists asking for a peer-to-peer review among the steps to take with your provider after a denial.
- KFF Health News, a health policy newsroom, advises asking your provider about a peer-to-peer review as part of fighting a denial.
- Patient communities describe it as something to ask the prescriber to request before a formal appeal for a prior authorization denial.
None of these gives a deadline in days or a federal right to a call. That means availability depends on your plan. Because the advice is to ask before a formal appeal, assume the window is short and may close once you appeal or soon after the denial. Your denial notice or the plan’s member services line can tell you.
What to do
- Ask the plan today (your step). Call the number on the denial notice or your member card. Ask: “Is a peer-to-peer review available for this denial? How long do we have to request it? How does my doctor request it?” Write down the answer, the date and the name of the person. Use the phone script for asking for a peer-to-peer review.
- Tell your doctor’s office (your step). Give them the denial notice, the case reference number and the deadline the plan gave. Ask who will make the call.
- Give your doctor a one-page brief. The peer-to-peer call brief is a page of notes in the doctor’s voice. The doctor fills in every clinical statement. It has three points to make, questions to ask the reviewer and what to write down.
- Help the doctor prepare (your doctor’s step). The doctor should have the plan’s stated reason and, if you have it, the plan’s rule. See how to find the insurer’s medical policy.
- The doctor makes the call (your doctor’s step). The doctor should ask for the reviewer’s name, specialty and licence, the criterion applied and what in the record it says is not met. The doctor should ask whether the reviewer can reverse the decision on the call and, if not, who can.
- Record the result. Write down the date, time, reviewer’s name, outcome and any reference number. Ask your doctor’s office to tell you the same day.
- Ask for the outcome in writing. Ask the plan to confirm it by letter or in the portal. If the denial stands, ask what it says about appeal rights.
- Appeal on time. The plan must give you at least 180 days after you receive the denial notice to appeal, and your plan may allow more. Check the date on your notice, which controls. This site found no federal rule that a peer-to-peer call stops that clock, so do not assume it does.
If it is urgent
If a physician who knows your condition says your claim is urgent, the plan must treat it as urgent, and a plan that is not grandfathered must defer to the attending provider’s decision. Urgent claims and urgent appeals must each be decided as soon as possible and no later than 72 hours. See how to get an expedited appeal.
What the plan may say, and what to say back
“A peer-to-peer is only available before a decision.” Ask in writing whether any other review is available now, and ask for the written explanation of your appeal rights. Then file your appeal.
“The window has closed.” Ask when it closed and where that time limit is written. Ask for the document. Then appeal, with your doctor’s letter.
“Your doctor can call, but the decision stays.” Ask who decides, and ask the doctor to record the reviewer’s reasons. Those reasons can go into your appeal.
The rule
If a physician who knows the patient’s condition says a claim is urgent, the plan must treat it as urgent, and a plan or insurer that is not grandfathered “shall defer” to the attending provider’s determination. See section 2560.503-1(m)(1)(iii) of Title 29 of the Code of Federal Regulations (CFR): 29 CFR 2560.503-1.
Watch for
- A call that goes nowhere. If the reviewer is not a doctor in your doctor’s field, or cannot change the decision, note it and move to your written appeal.
- Verbal promises. Do not rely on a promise on the phone. Ask for the result in writing.
- Pharmacy and drug denials. The route may differ. See the phone script for a pharmacy rejection.
- Medicare, Medicaid and other public coverage. These have their own appeal steps and timing. See Medicare and Medicaid and children’s coverage.
What next
- How to ask your doctor for a letter of medical necessity: your doctor’s written case.
- How to talk to your insurer on the phone: call habits that protect you.
- How to file an internal appeal: the written step that protects your rights.