Peer-to-peer
Preparing for a peer-to-peer review after a behavioral-health denial
A short, review-first way to prepare the treating clinician for a conversation with the payer's reviewer, and to document what was said.
Updated
Start with the payer's language
The notice or the payer's portal usually explains whether a peer-to-peer conversation is available, who may request it, and how long the window stays open. Note the reviewer's stated rationale and the criteria cited so the clinician can respond to each point specifically.
Before anyone drafts a response
- 01Confirm that a peer-to-peer is offered for this decision, who can request it, and the deadline to schedule it.
- 02Ask whether a reviewer in the same or a similar specialty is available, if the plan allows that request.
- 03Give the clinician a one-page summary: the stated reason, the cited criteria, and the record facts that respond to each point.
- 04Prepare neutral questions that clarify what documentation would change the determination.
What a review-ready file usually needs
- The denial notice and the cited criteria
- A one-page clinical summary tied to each stated reason
- The current treatment plan and recent progress documentation
- A call log: date, time, reviewer name and credentials, reference number, and outcome
- A next-step plan if the decision is upheld
Review cautions
- Only the treating clinician, or another qualified clinician, should make clinical arguments on the call.
- Record what the reviewer actually said; do not turn it into commitments the payer did not make.
- Availability, timing, and the effect of a peer-to-peer vary by payer and plan; verify them for each case.
What teams ask about this denial
Who should take a peer-to-peer call?
The treating clinician or another qualified clinician who knows the case. Billing or utilization-review staff can schedule the call and prepare the summary, but the clinical discussion should come from a clinician.
What should the clinician have ready?
The payer's stated reason and cited criteria, a one-page summary that ties specific record facts to each point, the current treatment plan, and a short list of questions about what documentation would change the decision.
What if the decision is upheld after the call?
Document the outcome and the reviewer's rationale, then check the remaining options in the notice, such as a formal written appeal and, where available, external review, along with their deadlines.
See the workflow on fictional data.
The denial lab extracts a reason, deadline, review points, and evidence checklist before drafting. No account or real patient data required.