What is a peer-to-peer review, and should my doctor ask for one?

What is a peer-to-peer review?

It is a conversation between your doctor and a clinician who works for your insurance plan. Your doctor explains your medical situation and why the service is needed, and the plan can reconsider its decision.

It is not the same as a formal appeal. A national review of state rules found that 26 states and territories have peer-to-peer provisions, and most commonly they give your doctor a chance to talk with a clinician of the same or similar specialty before a denial is considered final. If the conversation does not change the answer, you can still file a written appeal.

Can I ask for a peer-to-peer review myself?

Usually not. The conversation is between clinicians, so the request comes from the doctor who ordered the service. What you can do is ask your doctor's office to request it and give them the date on your denial letter.

Timing matters. Rules come from your plan and your state, so check your denial letter for any deadline or phone number and pass it to your doctor right away.

How quickly does a peer-to-peer review happen?

It depends on your state and your plan. In states that set a timeline, the conversation is often required within a few days of your doctor's request. For example, West Virginia says no longer than five days, Colorado within 5 calendar days, Indiana within 7 business days, and New Hampshire within 2 days.

State rules generally cover plans your state regulates, and they may not apply to every employer plan. Medicare, Medicaid, and some older plans can follow different rules. Your denial letter or your plan's website should say how to ask. If you cannot find it, call the number on your insurance card today.

What do I do if my doctor does not know about peer-to-peer reviews?

Most offices do, but a quick, friendly nudge helps. Here is a simple path.

You are not being pushy. You are helping a busy office act before a deadline.

• Step 1: Find the date. Look at your denial letter for the date and any deadline or phone number for a doctor-to-doctor review.
• Step 2: Call the doctor's office. Ask whether the doctor can request a peer-to-peer review with your insurance plan, and give them the date on the letter.
• Step 3: Send the letter. Give the office a copy of the denial letter and any notes on why the service matters to you.
• Step 4: Ask for the result in writing. After the conversation, ask what the plan decided and keep a copy. If the answer is still no, ask about a written appeal.

What if the peer-to-peer review does not change the denial?

You still have options. You can file an internal appeal. The HealthCare.gov guide says to file it within 180 days (6 months) of getting the denial notice. Your doctor or someone else can file it for you, and you can include a letter from the doctor. That guide covers most private health plans; Medicare, Medicaid, and some older plans have their own steps, so your denial letter is the final word on your deadline.

If the plan still says no, a denial involving medical judgment can go to external review by an independent reviewer. The HealthCare.gov guide says to request it within 4 months of the notice or final decision, and the insurer is required by law to accept the reviewer's decision. Your state's Consumer Assistance Program may also be able to help.

Is this legal or medical advice?

No. We are not lawyers, and this page is general information to help you ask better questions. Your plan's letter and your state insurance department have the rules that apply to you.

If you have a denial letter, text a photo of it to (213) 606-6303. We read it and reply with where it breaks. It is free, with no account and no form.

Your checklist

• Find the date and any deadline on my denial letter
• Call my doctor's office and ask them to request a peer-to-peer review
• Give the office a copy of the denial letter
• Write down who I spoke to and when
• Ask for the plan's decision in writing after the conversation
• Mark my appeal deadline from the denial letter on a calendar
• Text a photo of the letter to (213) 606-6303 if I am unsure where it breaks

A letter you can copy

Dear [Doctor's name] and team, My insurance plan, [plan name], denied [service or treatment] on [date of denial letter]. My member ID is [member ID]. A copy of the letter is attached. I understand a peer-to-peer review is a doctor-to-doctor conversation with the plan. Could you please request one as soon as possible? The letter says [deadline or "I could not find a deadline"], so I want to be sure we act in time. Please let me know what the plan decides, and whether I should also file a written appeal. Thank you for your help, [Your name] [Phone number]

Which rules apply to you?

The steps and deadlines on this page can differ by the kind of plan you have. Your own denial letter always comes first.

• Coverage through a job:ask your HR team whether the plan is “self-funded” or “fully insured.” It can change who you can ask for help. Most private-sector job plans fall under a federal law called ERISA, and the U.S. Department of Labor’s EBSA takes health plan questions at Ask EBSA or 1-866-444-3272.
• Marketplace plan: follow the appeal steps at HealthCare.gov.
• Medicare or Medicaid: each has its own appeal process, listed on your notice.
• Dental-only plan: your plan contract sets the appeal rights, so read it and your letter.

Related answers

• My appeal was denied. What now?
• Can I appeal a denied claim without a lawyer?
• How to read an insurance denial letter
• How to write an insurance appeal letter
• All answers

Free tools for the next step

Keep your appeal papers in one place. Take a photo of your denial letter, EOBs and insurance cards with GetPreCare, so they are on your phone when the insurer or the office asks. Free. Open GetPreCare. Helping a parent or partner? Set it up for them.