Purpose of the Peer-to-Peer (P2P)
Criteria for request
If you would like to request a P2P to discuss the denial of a physician-administered medication, please submit the Pharmacy Peer-to-Peer Review Request Form.
If the request does not meet these criteria and you wish to submit an appeal, please refer to the denial letter.
Fields marked with an asterisk (*) are required.
Is this request for a review that required consideration of the member's circumstances and is it related to a pre-service or concurrent review?
Do you understand a P2P conversation may not always be specialty-matched?
Do you understand that a P2P is a discussion (not an appeal) about a case to further understand the reason(s) for the denial based on our policies? A P2P is not intended to overturn a denial.
Note: New information about the service must be submitted as an appeal.
Is the provider who will be speaking with our medical director an eligible Peer (MD, DO, PA, or other Doctoral degree) and the patient's treating, ordering, or covering provider with knowledge of the patient's condition?
Is this the first P2P you have requested for this patient and service?
Note: Additional P2Ps are ONLY allowed for new/different denial on current reviews (i.e., a request to extend an inpatient hospital stay).
Do you understand that a P2P request will not be considered if an appeal has already been submitted?
Note: P2P requests for Medicare members will be considered regardless of whether an appeal has been submitted or not.
Provide at least two different call windows following these guidelines:
If we have any questions or a need to reschedule the time periods you indicated, we will select 2 call windows to contact you using the preferred physician's phone number provided.
If we have not been able to reach you in 2 of the call times provided, the peer-to-peer conversation will be considered completed and you may pursue the appeal process as applicable.
