The rules behind the tool
| Section | What to write | Why it matters |
|---|---|---|
| Denial rationale | The plan's reason, quoted | Keeps the call on the reviewer's actual objection |
| Criteria cited | Criteria set, edition and section | The reviewer decides against criteria, so you should too |
| Evidence per criterion | Dated notes, measures and events | Facts with dates move reviewers; adjectives don't |
| Risk if stepped down | What happened at lower levels; current safety concerns | The core level-of-care question |
| Three asks | Approve, or name the unmet criterion, or confirm the appeal route | Every call ends with a decision or a next step |
| Reviewer questions | License, specialty, criteria and records reviewed | Federal rules require reviewers with appropriate expertise |
How do I use the peer-to-peer prep sheet generator?
Fill in the level of care and dates at issue, quote the denial rationale, name the criteria the plan cited, then add one row per criterion with the dated evidence that meets it. Add the risk of stepping down and edit the three asks. The sheet updates as you type and prints on one page.
- 01Quote the plan's reason exactly as the notice or the reviewer stated it.
- 02Name the criteria set and section the plan cited. Don't paste licensed criteria text; describe each criterion in your own words.
- 03For each criterion, add the dated note, score or event that meets it. Two to four strong rows beat ten weak ones.
- 04Describe the risk of stepping down now with specifics: earlier step-downs and what followed, current safety findings, supports at home.
- 05Edit the three asks to fit the case, then print the sheet or copy it into the chart. Use initials, not names.
What is a peer-to-peer review, and is the plan required to offer one?
A peer-to-peer is an optional call where the treating clinician discusses a denial, or a pending request, with the plan's physician or clinical reviewer. Plans offer them under their own policies and provider manuals, often with short windows after the decision. It is not a formal appeal level, so the appeal deadline keeps running.
We found no federal rule that requires commercial or Medicare Advantage plans to offer peer-to-peer calls; the plan's provider manual sets whether they are available, who can ask and how fast. Federal rules do govern who may decide: a Medicare Advantage medical-necessity denial must be made by a physician or other appropriate health care professional with expertise in the relevant field (42 CFR 422.566(d)), and Medicaid managed care decisions by someone with appropriate expertise in the enrollee's medical or behavioral-health needs (42 CFR 438.210(b)(3)).
A peer-to-peer does not stop or extend the appeal clock. If the call fails, the written appeal still has to go in on time; use the appeal deadline calculator.
What should I ask the reviewer on a peer-to-peer call?
Ask the reviewer's name, license and specialty; which criteria set and edition were applied and which criterion is unmet; whether the notes for every date at issue were reviewed; and what the record would need to show to approve. Write the answers down: they shape the written appeal if the denial stands.
The credential question has a basis in the rules. On an ERISA appeal that turns on medical judgment, the plan must consult a health care professional with appropriate training and experience in the field of medicine involved, who was not consulted on the original denial and is not that person's subordinate, and must identify the medical experts whose advice it obtained (29 CFR 2560.503-1(h)(3)(iii) to (v)). A Medicare Advantage reconsideration based on medical necessity must be decided by a physician with expertise in the field appropriate to the services (42 CFR 422.590(h)(2)).
If the reviewer cannot name the unmet criterion, say so politely and ask that it be stated in writing. That request alone often clarifies whether the problem is clinical or documentation.
How do I make the clinical case in a few minutes?
Lead with the criterion the reviewer says is unmet, then give the two or three dated facts that meet it, then the risk of stepping down now. Stay with the record: dates, scores, incidents and what happened at lower levels of care. End with the first ask and stop talking.
- Open: "You cited [criterion]. Here is what the record shows for the dates at issue."
- Use numbers and dates the reviewer can check: scale scores, incidents, attendance, medication changes.
- Name what happened the last time the patient stepped down, and how fast.
- Connect each fact to the specific services only this level of care provides.
- Ask for the decision on the call; if it is still no, ask for the unmet criterion in writing.
What should I do after the peer-to-peer?
Log the call before anything else: date, time, reviewer, credentials, reference number, outcome and the reviewer's words about the unmet criterion. If the denial stands, file the expedited or standard appeal right away and attach what you learned. If it is reversed, confirm the authorization number and dates in writing.
If the plan relies on criteria you have not seen, request them with the criteria request letter. If the patient is still in care and the denial stands, an expedited appeal, and for group and individual plans expedited external review, may be available at the same time.
A residential step-down call
At Willow Creek Residential (fictional), the plan's reviewer proposes stepping a patient down to PHP on day 15, citing the criteria for continued residential care. The attending psychiatrist has a 2:30 pm call slot the next day.
The prep sheet lists two criteria in plain words, each with dated evidence: a relapse within 48 hours of the last PHP attempt, and withdrawal scores still rising on day 13. The three asks are approval of seven more days, the unmet criterion in writing if not, and confirmation of the expedited appeal route.
The reviewer approves five days. The psychiatrist logs the reference number and the reviewer's specialty, and the team calendars the next concurrent review.
Names, dates, payers and amounts are invented for illustration.
What a ClaimParrot packet adds
- Every level-of-care packet includes a peer-to-peer brief built from your de-identified summary: the opening statement, points with evidence, asks and reviewer questions.
- The same packet holds the appeal letter draft and the deadline plan if the call does not reverse the decision: $99, within 3 business days, first packet free (pricing).
- A person checks every packet before delivery (Trust & security).
Every draft is reviewed and approved by your team. ClaimParrot does not make medical-necessity determinations or give legal advice.
Frequently asked questions
Who should do the peer-to-peer call?
The treating physician or clinician who knows the patient best, ideally in the same field as the reviewer. Utilization review staff can prepare the sheet and join, but the reviewer expects a clinician who can answer questions about the patient directly.
Does a peer-to-peer replace the written appeal?
No. A peer-to-peer is an informal step set by plan policy. If the denial is not reversed on the call, the written appeal must still be filed within its deadline, and the call notes become part of the record.
Can I ask the reviewer about their credentials?
Yes. It is a fair question and the rules back it: ERISA appeals on medical judgment need a professional with appropriate training and experience in the field, Medicare Advantage medical-necessity reconsiderations need a physician with relevant expertise, and Medicaid decisions need appropriate behavioral-health expertise. Ask politely and record the answer.
Should I share the whole chart before the call?
Send what the criteria need for the dates at issue, not the whole chart. Psychotherapy notes and substance-use treatment records under 42 CFR Part 2 need extra care before they are shared; check consent and the minimum necessary.
What if the plan's peer-to-peer window has closed?
Go straight to the written appeal, expedited if the patient is still in care and waiting could seriously jeopardize them. Use the same prep sheet as the outline: the criteria, the dated evidence and the risk of stepping down translate directly into the appeal letter.
Primary sources and references
- 29 CFR 2560.503-1: ERISA claims procedure (appeal windows, decision clocks, claim-file access) · eCFR (National Archives) · checked
- 42 CFR 422.566: who may make an adverse medical-necessity decision · eCFR (National Archives) · checked
- 42 CFR 422.590: reconsideration timeframes and forwarding to the IRE · eCFR (National Archives) · checked
- 42 CFR 438.210: authorization decisions by a reviewer with appropriate expertise · eCFR (National Archives) · checked
- 29 CFR 2590.715-2719: internal claims, appeals and external review (group health plans) · eCFR (National Archives) · checked
General information, not legal or medical advice. The denial notice, the plan documents and state law control; state law can give more time or more rights than the federal floor shown here. Read our editorial policy.
Doing this for every denial in the queue?
Send one de-identified denial and get the appeal letter draft, evidence checklist and deadline plan back, checked by a person before it reaches you. $29 per appeal packet, $99 per level-of-care packet; your first packet is free.