Peer-to-peer reviews: the doctor-to-doctor call playbook

Why the call works

Insurance denials are usually first issued by an algorithm or a nurse reviewer applying screening criteria. The first level of physician review is often by an internal medicine medical director who never met the patient and is reading a one-page summary. The treating physician on a peer-to-peer call has information the medical director does not: the patient's functional status, the texture of prior treatment failures, the specifics of the clinical exam, and the actual treatment plan as it has been developing in the office. P2P calls produce reversals in part because they are the first time anyone clinically responsible at the plan hears the full case from the person actually treating the patient.

The second reason P2P works is regulatory. Under 29 CFR § 2560.503-1(h)(3)(iii) for ERISA plans, the plan must consult a health-care professional with "appropriate training and experience in the field of medicine involved" when the appeal involves medical judgment. State laws like New York Insurance Law § 4903, California Health & Safety Code § 1367.01, and Texas Insurance Code § 4201 impose parallel same-specialty requirements. P2P is the mechanism by which the treating physician forces the plan to comply with that rule on the record.

When to request a P2P

• After any adverse pre-authorization determination, before the final denial issues.
• When the plan's denial reasoning misstates the clinical facts or applies the wrong criteria.
• When the case involves complex specialty care (oncology, transplant, complex pediatrics, mental health) and the initial review was likely done by a non-specialist.
• For concurrent care reductions during an inpatient or residential admission - the P2P often determines whether the patient stays or is forced out.
• When time-sensitive treatment is at stake and a written appeal cycle would take too long.

Step 1: Schedule properly

The denial letter should list a P2P phone number; if not, the provider services line will route. When calling to schedule:

• Identify the case by member ID, claim number, and CPT/HCPCS.
• Demand a reviewer in the patient's specialty. State the specialty by name (e.g., "pediatric gastroenterologist," not "pediatrician"). Cite 29 CFR § 2560.503-1(h)(3)(iii) for ERISA plans or your state equivalent.
• Provide three time blocks the treating physician is available in the next two business days (one in next 24 hours if urgent).
• Get the reference number for the scheduled call and the name/credentials of the medical director who will be on the line.
• Confirm the call by fax or portal message the same day so there is a paper trail.

Step 2: Prepare a one-page case brief

The treating physician should walk into the call with a one-page printed brief containing:

1. Patient identifiers and date of denial.
2. Diagnosis with ICD-10 and the requested service with CPT/HCPCS.
3. Three-sentence clinical bottom line.
4. Bulleted prior treatments tried with dates and outcomes.
5. Two or three guideline citations: the specialty-society guideline (NCCN, AHA/ACC, AAN, ASCO, ACOG, APA, AAP, ASAM) and one or two PubMed-indexed studies that match the patient's profile.
6. The plan's published medical-coverage policy with each eligibility criterion mapped to the patient's facts.
7. What happens clinically if the denial is upheld.

Step 3: Run the call

A productive P2P is brief, clinical, and respectful. Most successful calls follow this arc:

1. Open (60 seconds). "Thanks for the time. I'm calling on [PATIENT NAME], DOB [DOB]. I have [PATIENT] for [DURATION] with [DIAGNOSIS]. We've tried [TREATMENTS] with [OUTCOMES]. The next step per [GUIDELINE] is [REQUESTED SERVICE], which was denied. I'd like to walk you through why this case meets the plan's criteria."
2. Apply the plan's criteria (3-5 minutes). "Looking at your published policy [POLICY NAME], the criteria are [LIST]. For criterion 1, the patient meets it because [FACT]. For criterion 2, [FACT]. ..."
3. Engage the medical director's concerns (3-5 minutes). Listen for what the reviewer cares about. If it is "have you tried first-line X" - answer it specifically. If it is "evidence base for the requested treatment" - cite the guideline and one trial.
4. Close (60 seconds). "Given that the patient meets every criterion in your policy and the requested service is supported by [GUIDELINE], I'd ask you to authorize coverage today. If you can issue a verbal approval, I'll have my office call back to confirm the auth number."

Step 4: Document the call immediately

As soon as the call ends, the treating physician (or a designee) should document in writing:

• Date, time, and duration of the call.
• Name, credentials, and specialty of the medical director.
• The clinical points discussed.
• The medical director's stated reasoning for upholding or reversing.
• The disposition: reversal (with auth number), upheld, or deferred for further review.
• Any procedural objections (non-specialty reviewer, refusal to consider new evidence).

Send the documentation to the patient and add it to the medical record. If the denial was upheld, this contemporaneous note becomes part of the appeal record - and if the reviewer was not in the relevant specialty, it becomes a procedural defect argument under 29 CFR § 2560.503-1(h)(3)(iii) or your state law.

If the medical director reverses on the call

• Demand a written confirmation by fax or portal upload within 24 hours.
• Get the authorization number on the call.
• Calendar a follow-up to verify the EOB pays the claim. Verbal reversals sometimes get lost in claim processing.

If the medical director upholds the denial

• Ask for the specific clinical reasoning in writing as part of the final adverse determination.
• Note any procedural defects: wrong specialty reviewer, refusal to consider supplied guidelines, refusal to engage with prior-treatment failures.
• Proceed with the written internal appeal, attaching the treating physician's letter of medical necessity. See our letter of medical necessity guide.
• File for external review under 45 CFR § 147.136 once internal appeals are exhausted. See our external review guide.

Demanding same-specialty review

If the medical director on the call is not in the relevant specialty, the treating physician should say so on the call, request a transfer to a same-specialty reviewer, and document the request in writing. Suggested language:

"Doctor, this case involves [SPECIALTY]. Under [29 CFR § 2560.503-1(h)(3)(iii) for ERISA / NY Insurance Law § 4903 / equivalent state law], this review must be conducted by a physician in the same specialty. With respect, your background in [REVIEWER'S SPECIALTY] is not the appropriate standard for this determination. I'd ask that you defer the decision and route this to a same-specialty reviewer for a second P2P before final determination."

State laws to know

• California: Health & Safety Code § 1367.01 requires utilization-review decisions to be made by a physician licensed to practice in California competent to evaluate the specific clinical issues.
• New York: Insurance Law § 4903 requires review by a clinical peer reviewer in the same or similar specialty as the provider rendering the service. Urgent P2P must be scheduled within one business day.
• Texas: Texas Insurance Code § 4201 and related provisions require same-specialty review and a documented opportunity for the requesting provider to discuss the case before adverse determination.
• Illinois: 215 ILCS 5/356z.4 governs adverse determinations and provides for prompt access to a clinical peer.

Common mistakes

• Skipping the P2P. Many practices treat P2P as a hassle and go straight to written appeal. The reversal rate on P2P is meaningfully higher.
• Sending a non-physician. Office staff cannot run a P2P. The treating physician must be on the call.
• Arguing policy language. Save the legal arguments for the written appeal. The P2P is clinical.
• Not preparing the brief. A treating physician trying to recall the case from memory will lose to a medical director reading from a denial template.
• Not documenting the call. Without contemporaneous notes, the procedural defects (non-specialty reviewer, refusal to consider evidence) cannot be raised later.

Frequently asked questions

See also: letter of medical necessity, ERISA appeals, external review and IRO, and prior authorization denial codes.