Phone script: ask for a peer-to-peer review
What to say to your doctor's office and your plan to ask for a call between your doctor and the plan's reviewing physician.
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- A template, not legal advice
When to use this, and what it is not
When to use this. When a plan has denied care on medical grounds and your doctor could explain the need directly to the plan's reviewer. A peer-to-peer review is a call between your doctor and the plan's reviewing physician. Plans set their own rules for when it is offered. It does not replace an appeal.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the script
Your script
Date of this call: [Date of the call] At the doctor's office: 1. Say: "My plan denied [The care or drug that was denied] on [Date on the denial notice]. I would like [Your doctor's name] to ask the plan for a peer-to-peer review. Can your office request it?" 2. Ask: "Who will handle this, and by what date will you ask?" Write down the name and date. 3. Ask: "Do you need anything from me, such as the denial letter or the plan's reference number?" At the plan (number on your card): 4. Say: "I am [Your name], member identification (ID) number [Member ID], calling about claim [Claim or reference number]. My doctor wants a peer-to-peer review." 5. Ask: "Does the plan offer a peer-to-peer review for this denial? By what date must my doctor ask? What number or form does the office use?" 6. Ask: "Does a peer-to-peer review change or pause my appeal deadline?" Do not assume it does. Write down the answer and keep your appeal date. 7. Ask: "If the review does not change the decision, can my doctor's office file the appeal for me, or do I need to sign a form?" 8. Ask for the person's name and a call reference number. Ask whether the call may be recorded, and write down their answer. 9. Write down: name, ID number, date, time, reference number, the promised action and the date. 10. Close: read your notes back and ask, "Is that right?" Say, "Thank you. I will call back on the date you gave me."
Before you call
Call your doctor's office first, then the member services number on the back of your insurance card. Ask the plan for a call reference number at the start and again at the end of the call.
What happens next
- Do not wait for the review. Keep working on your appeal, and keep your deadline.
- Ask your doctor's office to write a letter explaining why the care is needed. Plans must consult a health care professional with the right training when a denial rests on a medical judgment.
- Call the doctor's office a few days after the date they gave you, and write down the result.