Peer-to-peer update

This discussion affords a peer clinician the ability to provide/discuss clinical that may not have been provided on initial review and/or the ability to explain or clarify clinical that the peer provider believes is important in consideration of meeting medical necessity criteria.

The following providers can participate in a peer-to-peer conversation:

• Attending/treating/ordering physician
• A covering physician for the attending/treating/ordering physician
• The physician’s nurse practitioner or physician assistant
• The facility medical director or chief medical officer

Providers will have seven business days from the time of denial notification to request a
peer-to-peer review. A provider should call 732-744-6304 and leave a voicemail to request a peer-to-peer review and clearly provide the following information:

• Name of caller and telephone number
• Name of provider requesting the peer-to-peer
• Member ID number
• Brief details of request, such as the date of service

When a peer-to-peer review is requested within the seven days of denial notification, the health plan medical director will make a minimum of two attempts to contact the attending/treating/ordering physician in response to the request within those seven days:

• If the peer-to-peer was initiated timely (within seven business days) and denial notification was sent, but the medical director — despite attempts — was unable to complete the call within one business day, then one additional day will be allowed for a reconsideration.

For peer-to-peer reviews that result in a denial being upheld, the provider may communicate that they would like an expedited appeal, and the medical director will refer the provider back to their denial letter for instructions on how to request an expedited appeal.

A reversal or overturn of an adverse determination can be done during the peer-to-peer review conversation. At this time, the denial letter will be rescinded, and an approval notification/log will be faxed.

If the denial is upheld, the provider is directed to the appeal process noted in the denial letter.

We are committed to finding solutions that help our care provider partners offer quality services to our members.

What if I need assistance?

Availity Essentials Chat with Payer is available during normal business hours. Get answers to your questions about eligibility, benefits, authorizations, claims status, and more. Go to Availity Essentials and select the appropriate payer space tile from the drop-down. Then, select Chat with Payer and complete the pre-chat form to start your chat.

For additional support, visit the Contact Us section at the bottom of our provider website for the appropriate contact.