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            Conduct a Peer-to-Peer Review

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            Conduct a Peer-to-Peer Review

            As a medical director, clarify clinical information and explain review outcome decisions to the requesting provider by conducting timely peer-to-peer discussions.

            Required Editions

            Available in: Lightning Experience

            Available in: Enterprise and Unlimited Editions with Health Cloud
            User Permissions Needed
            To conduct peer-to-peer reviews: Health Cloud Utilization Management, OmniStudio User, and Salesforce Scheduler permission sets

            Use this meeting to bring alignment with the provider while retaining your focus on preventing unnecessary treatment, reducing rising healthcare costs, and meeting care quality. Based on the discussion, you can also override your previous decision of denial and approve the request.

            1. From the App Launcher, find and select the Utilization Management for Payers app.
            2. Select the case record to review.
            3. Click Start Peer-to-Peer Review.
            4. Review the up-to-date information of the request.
            5. If necessary, upload additional documents that you receive from the provider.
            6. In the Clinical Review section:
              1. Indicate the status of the clinical documentation and clinical guidelines based on your review.
              2. Select the approved level of care.
              3. Specify the approved quantity of each service or diagnosis code. Based on the requested and approved quantity, the decision for each item is auto-populated to Approved, Denied, or Partially Approved.
            7. In the Review Decision section, specify your decision on the request, the reason, and any notes or comments to maintain the audit history.
            8. In the Provider Call Details section, select the call outcome and record any notes.
            9. When you’re done, click Submit.
             
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