Winning the Peer-to-Peer Medical Review Call

A peer-to-peer medical review is your one shot to reverse a denial before it becomes a formal appeal, and most are lost in the first five minutes or won before the phone ever rings. This playbook gives you the pre-call documentation checklist, a call structure, turn-by-turn responses to 'not medically necessary' and 'step-down' rationales, and the post-call steps that protect your appeal record.

What is a peer-to-peer medical review and when is one triggered?

A peer-to-peer medical review is a phone conversation between your treating clinician and a payer's medical director or physician reviewer, held after a denial or adverse determination but before formal appeal. The goal is to argue medical necessity directly and, if successful, get the denial overturned on the spot.

P2P vs concurrent review vs formal appeal

Concurrent review happens during active treatment to authorize continued stay; P2P happens after a determination goes against you. Formal appeal is the written, formal process that follows if the call fails. Many state Medicaid programs require their managed care plans to offer the practitioner a peer-to-peer conversation within a defined window after an adverse determination, through the state contract and the plan's own utilization management policy (for example, this Louisiana Medicaid plan policy), so the call is often your fastest path to reversal. We walk through the call itself in more detail in our peer-to-peer review guide.

Who should take the peer-to-peer call: the treating physician or a delegate?

Most payers allow a licensed clinician involved in the patient's care to take the call, but rules vary: some require the treating physician or psychiatrist specifically, others accept an RN or therapist who can speak to the chart. Check the denial letter or plan provider manual before scheduling, because a call taken by a non-qualifying delegate can be counted as a failed review.

When you have the choice, put the treating psychiatrist on the call. The medical director is deciding whether the attending clinician's judgment supports continued residential, PHP, or IOP care, and first-hand clinical testimony about ASAM dimensions and length of stay carries more weight than a secondhand summary. If schedule conflicts force a delegate, brief them on the chart and keep the attending reachable for a three-way join. The same delegation discipline matters during concurrent reviews, not just initial determinations.

What documentation should you have open before the call starts?

The medical director will ask you to speak to specific ASAM dimensions, and every pause to search the chart reads as a gap in care. Open everything before dialing: most payer manuals give you a single call to make your case, and Aetna, Cigna, and UnitedHealthcare all expect the reviewer to speak to medical necessity criteria without a callback.

Pre-call documentation checklist

Mapping notes to ASAM dimensions

Tab each note to the dimension it supports. In the ASAM 4th Edition those are: intoxication, withdrawal, and addiction medications; biomedical conditions; psychiatric and cognitive conditions; substance use related risks; recovery environment interactions; and person centered considerations. The ASAM Criteria is the framework payers reference, so answering in their structure shortens the call. Track which dimension each payer's service request form emphasizes, because it varies. CriteriaIQ pulls the dimensional summary from Kipu or BestNotes automatically, so you are not rebuilding it from spreadsheets before every call (disclosure: I build it; see author profile). Where it falls short: it will not write your nursing notes for you, so chart hygiene stays on your team.

How should the first five minutes of the peer-to-peer call be structured?

Minute-by-minute opening script

Minute 0-1: confirm identities and the case. Give the reviewer the patient's member ID, level of care, and authorization or reference number, and confirm the reviewer's name and title. Ask whether the call is being recorded and say that you are recording too if your policy allows.

Minute 1-2: frame the review. State the level of care requested, the requested length of stay, and the admission date in one sentence. Then state the ASAM dimensions you will defend, for example: "This is a residential SUD request. I will speak to dimensions 1, 2, 4, and 5."

Minute 2-4: present the medical necessity case in ASAM order, not chronologically. Lead with your strongest dimension and the specific note that supports it.

Minute 4-5: state the ask and the deadline: "I'm requesting approval of X days retroactive to admission. The current authorization window closes Friday."

Asking the reviewer which criteria they are applying

Before presenting, ask directly: "Which criteria set are you applying, and which edition?" If the reviewer says MCG or InterQual rather than ASAM 4th Edition, say so on the record and ask for the specific criterion number. A mismatch between the payer's criteria and yours is easier to fix on the call than in a written appeal. Tracking which criteria each payor applies across your cases is exactly what CriteriaIQ is built for, so the answer is in front of you before the reviewer picks up.

How do you respond to common payer denial rationales like 'not medically necessary' or 'step-down level of care'?

Payer rationales on P2P calls follow a short list of patterns. Prepare a turn-by-turn response for each one before the call, anchored to the ASAM dimensional framework so your language matches the medical director's own criteria.

'Not medically necessary'

Ask the reviewer to name the specific dimension and criterion that failed. Then answer dimension by dimension: intoxication, withdrawal, and addiction medications; biomedical conditions; psychiatric and cognitive conditions; substance use related risks; recovery environment interactions; and person centered considerations. A residential denial usually collapses when you demonstrate that dimension 5 (recovery environment interactions) cannot support safety at a lower level of care.

'Step down to PHP/IOP'

Step-down denials are won on the recovery environment and substance use risk dimensions, not on clinical severity alone. Say plainly: "I'm not disputing that the patient has improved. I'm disputing that a step-down is safe." Then produce three facts: the patient's living situation (active using housemate, no sober supports, unstable housing), their documented relapse history at this exact transition point, and the specific risk event that would follow a premature move, such as untreated withdrawal returning or loss of housing before an IOP slot opens. If the payer's medical director hears severity numbers without an environment answer, they will uphold the step-down every time. If they hear a concrete environmental barrier tied to a documented relapse pattern, they have criteria-based grounds to continue the current authorization. Track which dimension each payor leans on, because the same argument structure repeats across your caseload, and logging the pattern in your UR workflow shortens the next call.

'Insufficient documentation'

Do not argue; fix it live. Offer to fax or upload the named missing item, usually a nursing note, ASAM assessment, or updated treatment plan, within the hour, and confirm the reviewer's fax number or portal on the call.

'Continued stay / length of stay'

Shift the frame from days used to days justified. Present the current treatment plan, measurable goals not yet met, and the planned discharge date with its destination. Reviewers continue stays tied to a specific, dated endpoint far more often than open-ended ones.

What should you do immediately after the call to protect the appeal record?

Write the call summary the same day, while details are fresh. Record the reviewer's full name, credentials, reference number, direct phone or fax, and the exact criteria they agreed or disputed. Note any commitment they made, such as approving additional days or sending written confirmation.

If the reviewer approved or partially approved the stay, ask for the confirmation letter and calendar a follow-up for when it should arrive. If it does not appear within the stated window, call back and reference the number.

Update your UR tracker immediately: outcome, denial rationale, agreed medical necessity criteria, and next deadline. If the call failed, capture the reviewer's stated rationale verbatim, because those notes become the backbone of the formal appeal.

When does a failed peer-to-peer review escalate to formal appeal, and how does the call notes support it?

If the reviewer upholds the denial, file the formal appeal within the payor's window, which is often 30 to 60 days from the denial notice for commercial plans; confirm the deadline on the actual denial letter, not on memory. Behavioral health denials are common enough that a lost appeal window is a preventable loss, not a rare one (KFF).

Your appeal packet should include the denial letter with its CARC/RARC codes, the full concurrent review note, ASAM 4th Edition dimension ratings, the treating physician's summary tied to medical necessity, and any service request forms already submitted.

Contemporaneous call notes matter here. Record the reviewer's name, the exact rationale given, and any admission that documentation was missing rather than clinically insufficient. That distinction converts a "not medically necessary" denial into a documentation-receipt dispute, which is a much easier appeal to win.

How do you run P2P calls at scale when you manage dozens of concurrent cases?

Block scheduling beats reactive calling. Reserve fixed P2P windows each day, and when a payor offers a slot outside them, take it anyway; a missed call date is often a de facto denial. Track every open authorization window in one shared tracker with payor, level of care, deadline, and call outcome, not a personal spreadsheet only you can see.

Spreadsheets break down past roughly a dozen concurrent cases: no reminders, no audit trail, and one missed deadline costs the entire stay. Ritten and Behave Health offer UR tracking as part of broader platforms, and Kipu Health supports concurrent review workflows within its EMR. CriteriaIQ runs alongside Kipu or BestNotes, surfacing authorization timelines and medical necessity gaps per case so nothing lapses while you are mid-call on another.

FAQ

What is a peer-to-peer medical review?

It is a phone conversation between your treating clinician and a payer's physician reviewer after an adverse determination, held before any written appeal. The clinician argues medical necessity directly, usually using the ASAM dimensional framework. If the reviewer is persuaded, the denial can be reversed immediately, making it the fastest available path to overturning a decision.

Can a nurse do a peer-to-peer review instead of the physician?

Sometimes, but check the denial letter or provider manual first. Some payers insist on the treating physician or psychiatrist, while others accept any licensed clinician involved in the patient's care who knows the chart. A call taken by a non-qualifying delegate can count as a failed review, so keep the attending available to join if needed.

What do you say on a peer-to-peer call?

Open by confirming identities and the case, then state the level of care, requested days, and which ASAM dimensions you will defend. Present your strongest dimension first with the supporting note, ask which criteria set the reviewer is applying, and close with a specific ask and deadline. If they say not medically necessary, make them name the failing criterion, then answer it dimension by dimension.

What happens if the peer-to-peer review is denied?

File a formal appeal within the payer's window, typically 30 to 60 days for commercial plans, confirmed against the actual denial letter. Your packet should include the denial letter with its codes, ASAM dimension ratings, the physician's medical necessity summary, and your call notes. Verbatim notes of the reviewer's stated rationale can reframe a clinical denial as a documentation dispute, which appeals far more easily.

How long do you have to request a peer-to-peer review?

It varies by payer and state. Many state Medicaid programs require plans to offer the practitioner the option within a defined window after an adverse determination, and commercial plans set their own timelines in the provider manual or denial letter. Treat the window as short: a missed call date often functions as a de facto denial, so schedule the call as soon as the letter arrives.