What Is a Peer-to-Peer Review? Everything Physicians Need to Know
A comprehensive guide to peer-to-peer reviews in healthcare. What they are, when to request one, what to expect, and how to succeed.
What Is a Peer-to-Peer Review?
A peer-to-peer (P2P) review is a phone conversation between the treating physician and the insurance company's medical director (or physician reviewer) to discuss a prior authorization that was denied.
The purpose is to give the treating physician an opportunity to present additional clinical information that wasn't captured in the initial review, and to discuss the medical necessity of the requested service.
When Should You Request a P2P?
You should request a P2P when:
A prior authorization is denied for medical necessity
You believe the reviewer didn't have complete clinical information
The denial is based on criteria that your patient actually meets
The clinical situation is nuanced enough that a conversation would help
You probably shouldn't request a P2P when:
The denial is for administrative reasons (coding, timely filing)
The service genuinely isn't covered under the patient's plan
You don't have a strong clinical argument for the requested service
What to Expect During the Call
A typical P2P call lasts 5-15 minutes. Here's what happens:
**Introductions.** The medical director introduces themselves and their specialty.
**Case summary.** You briefly summarize the clinical situation.
**Discussion.** The medical director may ask questions, raise concerns, or suggest alternatives.
**Decision.** The medical director may overturn the denial on the call, or may need additional time to review.
Your Rights
You have the right to request a P2P for any medical necessity denial
You have the right to know which criteria set was used for the denial
You have the right to speak with a physician reviewer (not just a nurse reviewer)
Some states require the reviewing physician to be in the same specialty
Tips for Success
Prepare.Don't wing it. Have your talking points ready.
Be concise.The medical director has a busy schedule. Get to the point.
Be collegial.This is a physician-to-physician conversation, not a courtroom.
Present new information.Don't just restate the chart. Share context the reviewer may not have.
Know the criteria.Understand what standard they applied and why your case meets it.
*New to P2P calls? Try our free prep tool to generate a structured script before your first call.*
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