How do you win a peer-to-peer review with a payer?
Short answer
A peer-to-peer review is a call between the treating or advising physician and the payer's medical director about a denial or a pending adverse decision. You improve your odds by calling quickly, having a short clinical timeline ready, tying the facts to the payer's own criteria and documenting the outcome. If the call doesn't succeed, the case moves to a written appeal.
Last reviewed by board-certified physician advisors
Before the call
- Check the deadline. Payers often allow only a short window after the denial notice. It varies by payer and contract.
- Write a 3–4 sentence summary: presenting problem, key findings, treatment and why it required hospital care.
- Find out which criteria were applied (InterQual, MCG or the plan's own policy) and which one wasn't met.
- Check the plan type. For Medicare Advantage, the Two-Midnight Rule applies to inpatient admissions.
- Have the record open: vitals, labs, imaging, treatments and timing.
During the call
- Lead with severity of illness and the risk if the patient hadn't been in the hospital
- Stick to facts in the record; don't argue beyond it
- Ask which specific criterion the reviewer believes wasn't met, then answer it directly
- Name the rule when it applies, for example the Two-Midnight Rule for Medicare Advantage
- Get the reviewer's name and a reference number before hanging up
After the call
- Document the date, reviewer, discussion and outcome in the record
- If the denial is upheld, start the written appeal right away, using what you learned on the call
- Track outcomes by payer and reason to spot patterns worth raising with the payer or your contracting team
Key terms
Common questions
Who should do the peer-to-peer call?
The attending physician or a physician advisor. A physician advisor who does these calls every day usually knows the criteria and how to frame the case, and it saves attending physicians time.
How long do you have to request a peer-to-peer?
It depends on the payer and your contract, and some windows are only a few days. Check the denial letter and your payer agreements, and request the call as soon as the denial arrives.
What if the payer won't schedule a peer-to-peer?
Document every attempt with dates and times, then move to a written appeal. Repeated scheduling problems are worth raising with the payer's provider relations team.
Talk with a physician advisor
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