An orthopedic surgeon we work with used to take peer-to-peer calls between patients, from memory, with the chart closed. He won about a third of them. After his office started preparing a one-page brief and scheduling the calls at the end of clinic, he won most of them. The medicine did not change. The preparation did.
Knowing how to prepare for a peer-to-peer review is a practice skill, not a clinical one, and it is one of the few places in the prior authorization process where the physician's time buys a direct result. The call is short, usually under ten minutes. The reviewer has the payer's criteria in front of them and often nothing else. The physician who arrives with the criteria, the chart facts that meet them, and a clear request wins far more often than the one who arrives with a strong opinion.
A glossary line: a peer-to-peer (P2P) is a telephone conversation between the treating physician and a physician employed or contracted by the payer, offered after a prior authorization request is denied or pended for medical necessity, and before or in place of a written appeal. It is not an appeal in the legal sense, and requesting one does not always stop the appeal clock.
Key takeaways
- Request the peer-to-peer immediately; many payers allow only a short window after the denial, often 5 to 14 calendar days, and some close it once a formal appeal is filed.
- The physician should have three things on the desk: the payer's clinical criteria, a one-page brief mapping chart facts to each criterion, and the specific request.
- Ask the reviewer's name, specialty and the criteria they are applying before the clinical discussion begins.
- Every call ends with a stated outcome and a reference number; if the reviewer says "approved," ask when the written approval will be issued and to whom.
- Track peer-to-peer outcomes by payer and reviewer; the data tells you which denials are worth a call and which should go straight to written appeal.
Timing: the window closes fast
The denial letter or portal message states whether a peer-to-peer is available and how to request it. The windows vary. Some Medicare Advantage plans offer the call only before the formal reconsideration is filed. Some commercial plans give five business days from the denial. A few allow the call at any point before the appeal decision. The practical rule is to request the call the same day the denial arrives and to write the deadline on the request.
Scheduling is its own problem. Payers typically offer a callback window ("the reviewer will call between 1 and 4 pm Thursday") rather than a fixed time, and the physician has to be reachable with the chart open. We recommend a standing block at the end of one clinic session per week for these calls, and a direct line the payer can reach that bypasses the front desk queue. A missed callback often counts as a forfeited peer-to-peer.
| Payer type | Typical peer-to-peer availability | What to confirm when requesting |
|---|---|---|
| Medicare Advantage | Usually offered before the reconsideration is filed; expedited cases may be handled within 72 hours | Whether requesting the call delays the plan's decision deadline, and whether the reviewer will be in the same specialty |
| Commercial (fully insured) | Commonly 5 to 14 calendar days from the denial; state law may set reviewer requirements | The exact deadline, the callback window and the phone number the reviewer will use |
| Self-funded employer plans | Set by the plan document and the administrator | Whether the call is a formal step or informal; formal appeal rights under ERISA are separate |
| Medicaid managed care | Varies by state contract; often available and sometimes required before appeal | State fair hearing rights run separately and have their own deadlines |
| Utilization management vendors (imaging, sleep, genetic testing) | Often available through the vendor's own portal, on a short window | Which entity issued the denial; the vendor's peer-to-peer is separate from the plan's appeal |
The one-page brief
The single most effective change a practice can make is to hand the physician a one-page brief before the call. A staff member, usually the authorization coordinator, prepares it from the denial letter and the chart. It has five parts.
- The request. The exact service, code and setting denied: "MRI lumbar spine without contrast, CPT 72148, outpatient." And the denial reason quoted from the letter.
- The criteria. The payer's clinical policy name and number, and the specific criteria the denial says were not met. If the letter does not name the policy, the coordinator calls and gets it. Payers are generally required to disclose the criteria used.
- The facts, mapped. For each criterion, the chart fact that satisfies it, with the date and the location in the record: "Criterion: six weeks of conservative therapy. Fact: PT 3/4 to 4/22, 8 sessions, notes attached; NSAIDs since 2/28, med list."
- The gap, if any. Where the record is thin, say so and say what the physician will argue: "Criterion requires neurologic deficit; exam 4/30 documents diminished L5 sensation, not in the original submission."
- The ask. "Approve 72148 as requested" or "approve with modified units." Not "please reconsider."
This takes the coordinator 20 to 30 minutes. It saves the physician the time of reading the chart cold and, more importantly, keeps the conversation on the payer's criteria rather than on general clinical judgment, which the reviewer is not permitted to substitute for the criteria anyway.
A five-minute script
Physicians do not need to read from a script, but the sequence matters. Open by getting the reviewer's information: "Before we start, may I have your name, your specialty and the clinical policy you are applying?" This is not hostile. It establishes the ground rules, and if the reviewer is outside the specialty, the physician can ask for a same-specialty review, which Medicare Advantage rules and several state laws support.
Then state the case in the payer's terms: "Your denial says the request did not meet criterion 2, six weeks of conservative therapy. The patient completed eight sessions of physical therapy between March 4 and April 22 and has been on an NSAID since February 28. That is more than six weeks." Move criterion by criterion. Where the record has a gap, address it directly: "The exam on April 30 documents a sensory deficit, which was not in the packet you received; I can fax it now."
Close with the ask and the logistics: "I am asking you to approve the MRI as requested. Can you approve it on this call? If so, what is the reference number, and when will the written approval reach my office?" If the reviewer declines, ask what additional information would change the decision and whether the case will proceed to formal appeal automatically or requires a new filing. Write both answers down.
Documenting the call
The call is worthless if the outcome is not captured. Immediately after, the physician or the coordinator records: date and time, reviewer name and specialty, criteria discussed, outcome, reference number, and any commitments (fax this, expect approval by Friday). Put it in the authorization log and in the chart. When a verbal approval fails to become a written one, the note with the reviewer's name and the reference number is what gets it fixed. When the denial is upheld, the same note becomes the first paragraph of the written appeal.
We also recommend recording the peer-to-peer outcome by payer, by reviewer and by service in a simple spreadsheet. After a few months the pattern is usually plain: certain payers approve on the call most of the time, certain services never move without a written appeal, and certain utilization management vendors are not worth the physician's time. That is how a practice decides where to spend its scarcest resource. If the tracking, scheduling and brief preparation is more than the office can staff, it is part of what our denial management team does for practices.
Questions we hear
Can a nurse practitioner or the practice's coordinator do the peer-to-peer?
Most payers require the ordering or treating clinician, and many require a physician if the reviewer is a physician. Some allow an NP or PA who is the treating clinician. The coordinator can schedule and prepare but generally cannot conduct the call. Ask the payer when requesting.
Does requesting a peer-to-peer delay the appeal deadline?
Not necessarily, and this trips practices up. Some payers treat the peer-to-peer as informal and keep the appeal clock running from the original denial. If the call is scheduled near the end of the appeal window, file the written appeal in parallel rather than waiting.
The reviewer said approved on the call but the portal still shows denied. What now?
Call the payer with the date, the reviewer's name and the reference number, and ask for the written determination. If it is not resolved within a few business days, file the written appeal and attach your documentation of the verbal approval. Do not schedule the procedure on a verbal approval alone.
What to do this week
- Pull the last ten medical necessity denials and check each letter for the peer-to-peer window and request method; record the pattern by payer.
- Create the one-page brief template with the five sections and assign who prepares it.
- Block a standing weekly time on each physician's schedule for payer callbacks and give payers a direct line for that block.
- Add reviewer name, specialty, criteria, outcome and reference number fields to the authorization log.
- Start tracking peer-to-peer outcomes by payer and service so the practice can decide which denials justify the call.
