Peer-to-peer (P2P) review

What it is

Peer-to-peer review is a direct phone consultation between the prescribing physician and the plan's reviewing physician (or PharmD). It's often offered as an informal step before or alongside the written internal appeal. The reviewing professional has the authority to overturn or uphold the denial in real time based on the clinical conversation.

Who can use it

Prescribing physicians and (sometimes) other prescribers (NPs, PAs). Patients and family members cannot directly request a P2P — it must come from the clinician.

When to use it

After a denial when the plan offers peer-to-peer review and the treating clinician can concisely address the plan's stated rationale. Confirm the purpose, deadline, reviewer role, and whether the discussion preserves formal appeal rights before relying on it.

Steps

1. Call the plan and request the P2P. The denial letter usually has a P2P request number. Calling first is often faster than written request.
2. Prepare the clinical pitch (5 minutes). Diagnosis, guideline support, prior-therapy history, why this specific therapy now, what alternatives have been considered/tried/contraindicated.
3. Get on the call yourself. Plans often try to put MAs or nurses through. The reviewing physician needs to talk to the prescribing physician — that's the leverage.
4. Reference the published criteria. Most plans' published medical policies are searchable. Cite the specific policy section that supports the request.
5. Document the outcome. If approved, get the authorisation number in writing immediately. If denied, ask for the written reason and proceed to formal internal appeal.

Key deadlines