How to Request a Peer-to-Peer Review With Your Insurer

What Is a Peer-to-Peer Review?

A peer-to-peer review is a direct conversation between your ordering physician and the insurer's medical reviewer. It is one of the most powerful — and least used — tools available when a clinical service is denied.

Unlike a formal written appeal, a peer-to-peer review happens by phone, often within days of the denial. Your physician explains the clinical rationale directly to the insurer's reviewer. No forms. No waiting months. Many denials are overturned before a formal appeal is ever filed.

When to Request a Peer-to-Peer Review

Peer-to-peer reviews are most effective for:

• Medical necessity denials — CO-50 and similar codes
• Prior authorization rejections
• Denials for procedures or imaging the insurer says don't meet their clinical criteria
• Mental health and behavioral health denials
• Specialty medication denials

They are less useful for administrative denials — wrong codes, missing information, timely filing issues — where the dispute is not clinical.

How to Request a Peer-to-Peer Review

Step 1 — Act quickly

Most insurers allow peer-to-peer requests within a short window after the denial — typically 5 to 14 days. Check your denial notice for the specific timeframe.

Step 2 — Call the peer-to-peer line

Your denial notice or EOB will include a phone number for physician services or peer-to-peer reviews. If it is not listed, call the main provider services line and ask specifically for the peer-to-peer review department.

Step 3 — Have your physician make the call — not you

The peer-to-peer review is a physician-to-physician conversation. Your ordering physician — not you — must call. The insurer will not conduct a peer-to-peer review with a patient.

Step 4 — Prepare your physician

Before the call, your physician should review your complete medical record, the denial reason and clinical criteria applied, and any published guidelines supporting the medical necessity of the denied service.

Step 5 — Request a decision in writing

After the peer-to-peer review, ask for the insurer's decision in writing. If the service is approved, confirm the authorization number before proceeding.

What Your Physician Should Say

Your physician's goal on the call is to establish threthings:

• The clinical basis for the ordered service — diagnosis, symptom history, functional impact
• Why less expensive alternatives were tried, failed, or are clinically inappropriate
• Why the denied service is the appropriate next step given the patient's clinical history

The conversation should reference the insurer's own clinical criteria and demonstrate how the patient's case meets those criteria — not argue that the criteria are wrong.

If the Peer-to-Peer Review Fails

If the peer-to-peer review results in an upheld denial, file a formal written appeal immediately. The peer-to-peer discussion gives you valuable information — you now know exactly what the insurer's reviewer believes is missing from the case. Address those specific points in your formal appeal.

How ClaimCompass Helps

ClaimCompass generates your formal written appeal letter after a failed peer-to-peer review, addressing the specific clinical arguments the reviewer raised.

Upload your denial at myclaimcompass.ai for a free analysis.

Frequently Asked Questions

Is a peer-to-peer review the same as a formal appeal?

No. A peer-to-peer review is informal and happens before a formal appeal is filed. It does not affect your appeal rights or deadlines — you can still file a formal appeal after a peer-to-peer review if the denial is upheld.

Does requesting a peer-to-peer reviewextend my appeal deadline?

No. Continue tracking your appeal deadline even while a peer-to-peer review is pending. If the review is not resolved quickly, file your formal appeal to protect your rights.