Peer to Peer Review Questions: A UR Guide

A peer to peer review is a phone call between your clinical staff and a payor's medical director, held when a concurrent review or prior authorization is denied or at risk of denial. This guide answers the questions UR coordinators and UR nurses ask most: when payors require a P2P call, who should take it, what ASAM-based questions to expect, and how to prepare, run, and follow up on the call so a denial does not stand.

What Is a Peer to Peer Review in Behavioral Health?

A peer-to-peer review is a phone call between your treating clinician and a payor's medical director or licensed reviewer, held after an adverse determination, to argue medical necessity clinician-to-clinician. It differs from a standard concurrent review because you are talking directly to a peer with authority to overturn, not submitting documents into a queue.

Peer-to-peer vs concurrent review vs retrospective review

Concurrent review happens during active treatment: a UR nurse submits clinical updates and ASAM 4th Edition dimensional criteria to justify continued stay. Retrospective review happens after discharge, when the payor audits records for services already delivered. A P2P call is the escalation path when concurrent review fails, and most plans, including many Medicare Advantage plans, let the treating provider request one and discuss the case with the plan's reviewer (Wellcare provider bulletin). Timing matters: many payors set short windows, often just a few business days, to schedule the call before the denial finalizes.

When Will a Payor Request a Peer-to-Peer Call?

Payors typically request a P2P when a concurrent review comes back denied or pended on medical necessity, when a service request form lacks the clinical detail to support the ASAM level of care, or when an initial authorization is contested. You may also get one after a length-of-stay extension request or a step-down dispute.

Authorization windows and deadline risk

Most payors give you a short window, often 5 to 10 business days, to schedule and complete the call before the denial becomes final. Miss it and your appeal path narrows considerably. Because each payor sets its own timeline, tracking authorization windows across dozens of concurrent cases in spreadsheets is where cases slip. CriteriaIQ RCM tracks each case's deadline inside your existing workflow so nothing lapses; it does not make the call for you, and your clinical documentation still has to carry the medical necessity argument. For a broader look at tooling, see our guide to utilization review software for behavioral health.

Who Should Take the Call?

Most payors do not require the treating clinician, but they do require someone at or above the reviewer's licensure level: a physician for a physician reviewer, or an RN or licensed clinician for a behavioral health reviewer. Provider manuals typically specify who may participate and the scheduling window you must meet, so check your payor's UR policy before the call (Aetna provider resources).

Matching reviewer level to level of care

For residential and detox cases, put your medical director or an ASAM-familiar physician on the line. For PHP and IOP step-down requests, an experienced UR nurse armed with the chart can hold medical necessity against the reviewer's criteria. If your UR nurse runs the call, have the treating clinician available for escalation, and log the outcome in Kipu so nothing lives only in a shared inbox. Steven Cavan covers reviewer credentialing in more depth on the CriteriaIQ author page.

What Questions Do Payors Ask on a Behavioral Health P2P Call?

Payor reviewers structure P2P questions around the six ASAM dimensions. If you can answer each dimension with a specific clinical finding and a dated document in the chart, the call stays short and the authorization holds.

ASAM Dimension 1: intoxication, withdrawal, and addiction medications

Expect questions on current substance use, last use date, withdrawal history, and CIWA/COWS scores. For detox and residential levels, the reviewer wants to know whether withdrawal risk requires 24-hour monitoring and what your protocol is if scores escalate.

ASAM Dimensions 2-3: biomedical and psychiatric and cognitive conditions

Here the questions cover comorbid conditions, current medications, recent medical events, and psychiatric acuity: suicide risk, prior hospitalizations, and medication changes. The reviewer is checking whether your level of care matches the medical and behavioral risk, not just the diagnosis on the service request form.

ASAM Dimensions 4-6: substance use related risks, recovery environment, person centered considerations

These are the questions UR nurses most often underprepare for. Expect: what engagement looks like in the chart (attendance, participation, treatment alliance), recent relapse history and triggers, and the home environment. A patient returning to the same living situation with active using contacts is a stronger residential argument than any diagnosis list.

Level-of-care and step-down questions

The reviewer will ask directly: why can this patient not be treated at a lower level of care, and what would make them ready to step down? Your answer should name the ASAM dimension that fails at the lower level, the specific service only your level provides, and your step-down plan with a timeline. Vague answers like "the patient needs more structure" trigger denials; dimension-specific answers with documentation do not.

Every question above maps to a chart document you should have open before the call. CriteriaIQ organizes concurrent-review documentation by ASAM dimension so you can pull the answer, not search for it mid-call.

How Do You Prepare for a Peer-to-Peer Call?

Preparation is the difference between a five-minute approval and a denial letter. Pull the chart, map the client to ASAM dimensions, and know your numbers before you dial.

Documents to have open before dialing

Have these ready in a second browser tab or printed:

• The most recent ASAM assessment and the level-of-care recommendation with the dimension ratings.
• Notes since admission: nursing notes, group participation records, medication changes, UA results.
• Length of stay so far and the payor's authorized dates.
• The denial or pending determination letter, with the reviewer's name and callback number.
• Your payor-specific criteria reference, since some plans use InterQual or MCG instead of ASAM.

The ASAM Criteria 4th Edition organizes assessment across six dimensions, and payor reviewers speak that language. If your notes are not organized by dimension, restructure them before the call.

The peer to peer review template in action

Use a one-page template per client: presenting problem, dimension summary, treatment response, risks of step-down, and your specific ask (continued stay dates, level of care). Tools like CriteriaIQ keep concurrent review timelines and documentation against each payor's medical necessity criteria inside Kipu, so the template is populated instead of rebuilt from spreadsheets. Where it falls short: it will not write your clinical argument for you. The dimension-by-dimension rationale still comes from the chart and from you.

What Should You Say (and Avoid Saying) on the Call?

Framing medical necessity in ASAM terms

Anchor every statement to the dimension the payor is reviewing. Say "the patient meets ASAM 4th Edition Dimension 1 for residential because withdrawal management requires 24-hour observation," not "the patient is doing poorly and needs more time." Cite specific findings: COWS scores, medication changes in the last 72 hours, the most recent nursing assessment. Vague language like "not stable enough" invites a downgrade; a dated, dimensional fact is hard to argue with.

Handling the 'why not a lower level of care' question

This is the question that decides most step-down disputes. Answer with the ASAM dimensions that block the step-down, concretely: "PHP would require the patient to self-administer medication overnight, and Dimensions 4 and 5 show two relapses in prior PHP attempts and unsupportive housing." Avoid defensive phrasing like "the doctor won't approve that" or "insurance already authorized this level last month." Both read as appeals to authority rather than clinical reasoning, and reviewers treat them as concessions. If you don't have a dimension-specific answer on hand, say you'll send documentation within the hour and log the follow-up, rather than guessing on the call.

What Happens After the Call?

Getting the determination in writing

Never accept a verbal approval as final. Ask the payor reviewer to state the approved level of care, authorized units or days, and the end date on the call, then request the determination letter and confirm the authorization number appears in Kipu. Log the reviewer's name, NPI, and call timestamp the same day, while details are fresh.

Denial codes and next steps

If the call ends in a denial, get the specific reason and match it to the CARC/RARC codes on the remittance. An ASAM-based denial ("does not meet 3.5 criteria") is appealable with a focused re-summary; an administrative denial (timely filing, missing service request form) is usually a corrected-claim fix, not a clinical argument. Behavioral health practices lose 10-20% of potential revenue to preventable denials, so every code you capture now shortens the appeal later (Pimsy). Check the payor's appeal deadline immediately and calendar it.

How Do You Track P2P Calls Across Multiple Payors Without Losing Cases?

Where manual tracking breaks down

Spreadsheets and shared inboxes fail at the same three points: the authorization window, the peer-to-peer deadline, and the concurrent review due date. Each payor runs its own timeline, so a case can be current in one column and already past due in another. A single missing note or delayed assessment can trigger hours of rework or an automatic denial, and nothing in a spreadsheet flags it before that happens.

What UR software handles instead

UR software built for behavioral health ties each case to its payor's criteria and deadlines, then surfaces what is due today rather than making you sort rows. Here is how the options compare:

Honest limitation: CriteriaIQ does not replace your clinical judgment on the call. It keeps the dates and documentation in front of you so a case never slips because a spreadsheet row got missed.

FAQ

What is a peer to peer review in medical insurance?

It is a phone call between your treating clinician and a payor's medical director, held after a denial, to argue medical necessity clinician-to-clinician. Unlike a standard concurrent review, you speak directly with someone who has authority to overturn the decision, rather than submitting documents into a review queue.

How long does a peer-to-peer review take?

The call itself is often short. If your documentation answers each ASAM dimension with specific, dated clinical findings, an approval can come in minutes. The harder constraint is scheduling, as payors set 5 to 10 business day windows to complete the call before the denial finalizes.

Can a nurse do a peer-to-peer review or does it have to be a doctor?

Usually a nurse can. Most payors require someone at or above the reviewer's licensure level: a physician for a physician, or an RN for a behavioral health reviewer. Check the payor's provider manual, and keep the treating clinician available for escalation on residential and detox cases.

What happens if you miss the peer-to-peer deadline?

The denial typically becomes final, and your appeal path narrows considerably. Each payor sets its own scheduling window, so a case can be current with one plan and already past due with another. Spreadsheets fail here because nothing flags a lapsed window before the deadline passes.

Is a peer-to-peer denial final?

No. Get the specific denial reason and match it to the CARC/RARC codes on the remittance. An ASAM-based denial is appealable with a focused clinical re-summary, while an administrative denial is usually a corrected-claim fix. Check the payor's appeal deadline immediately and calendar it.